Perinatal Mood Disorders: Research & Clinical Implications. Emma Robertson Blackmore PhD. Assistant Professor of P

1. Perinatal Mood Disorders: Research & Clinical Implications. Emma Robertson Blackmore PhD. Assistant Professor of Psychiatry (Psychology)

2. Definitions • Antenatal = antepartum = before birth • Postpartum = postnatal = puerperal = puerperium • All following childbirth • Parturition = giving birth = delivery • Perinatal = time surrounding pregnancy and the postpartum period

3. Antenatal Mood Disorders Myth that pregnancy is ‘protective’ against psychiatric disorders. Severe psychiatric episodes are less frequent during pregnancy. Research has shown women experience anxiety and depression during pregnancy at the same rate as postpartum 10-15% (Heron et al.,2004) .

4. Why are antenatal disorders important? • Prenatal mood contributes to poor infant and child outcome • Maternal anxiety directly affects fetal behavior and heart rate • Pregnant women with high levels of mood disturbance and/or stress have double the risk of preterm birth or fetal growth restriction compared to those women reporting low levels of stress, independent of other established obstetric and sociodemographic factors • Prenatal maternal depression is significantly associated with low birth weight, premature labor and delivery, and pre-eclampsia & infant temperament.

5. Detection of antenatal symptoms • Women’s reluctance to disclose symptoms / stigma • Don’t realize it’s pathological • Focus of primary care physician on physical health of mom and baby • What would PCP do if detected depression? • Standardized questionnaires e.g. Edinburgh Postnatal Depression Scale

6. Puerperium & Affective Disturbance • Three-fold risk of having non-psychotic depressive disorder in first month postpartum (Cox et al.,1993) • 22-fold increased risk of affective psychosis following childbirth (Kendell at al.,1987) • The chance of psychiatric admission during the first four weeks postpartum is 18 times greater than during pregnancy (Paffenbarger,1982)

7. Postpartum Psychiatric Disorders

8. ‘Blues’ • Most common perinatal mood disturbance • Prevalence: 30-75% • Onset day 3 or 4 • Mild, transient lasting hours to days • Resolve within 2 weeks • No treatment necessary

9. Postpartum Depression • Most common complication of childbirth • Prevalence: 10-15% • Onset after 2 weeks, usually up to 6 months • Duration: weeks to months • Treatment: family doctor or psychiatrist • Psychological interventions or medication

10. Postpartum Psychosis • Most rare and severe form of postpartum mood disorder • Prevalence: 0.01-0.02% • Onset: rapid, within 72 hours of birth, 95% of cases within 2 weeks • Treatment: Psychiatric Emergency, Psychiatrist – treatment with medication

11. Postpartum Depression. • Most common complication of childbirth affecting an average of 13% of moms (O’Hara & Swain,1996) • Non-psychotic depression that occurs shortly after childbirth • DSM-IV states onset within 4 weeks • Research and clinical experience varies – up to 6 months is usual, 1 year generous

12. PPD - continued • High risk of further episodes • Further episode following childbirth is 40-60% • Estimated risk of depression unrelated to childbirth is 25% • Symptoms can be difficult to distinguish from normal sequelae of childbirth • Women can be reluctant to disclose symptoms

13. Is PPD different from other depressions? • No – clinically no different from depression occurring at other times • Diagnostic criteria is DSM-IV with postpartum onset specifier • Not surprisingly, the content of symptoms often focuses on motherhood or infant care topics

14. Diagnostic Problems • Differentiating between clinical symptoms of depression and normal sequelae of childbirth • Fatigue, sleep disturbance, weight change, appetite disturbance, diminished concentration, libido • Reluctance to disclose symptoms or to recognize them as pathological

15. Antenatal Risk Factors for PPD Robertson E et al. Antenatal risk factors for postpartum depression: A synthesis of recent literature. General Hospital Psychiatry 2004 July-August; 26(4):289-295 Strong Antenatal depression Antenatal anxiety Family or previous history of depression Stressful life events Lack of social support Moderate Maternal personality (neuroticism) Low self-esteem Relationship difficulties Weak Low SES Obstetric & Pregnancy Complications

16. Hormonal Vulnerability as a Triggering Model of PPD • Bloch et al (2000) scaled-down model to simulate pregnancy and childbirth • 8 women with a hx of PPD, 8 without • Both groups given gonadal-releasing hormone over an 8 week period and then these were withdrawn to simulate childbirth • 5/8 women with hx developed depression • Support for sub-group of women vulnerable to hormone changes following childbirth

17. Treatment • PPD very treatable illness • 70-80% of women recover with treatment • Antidepressants (issues relating to breastfeeding) • Psychotherapy – CBT, IPT, • Supportive counseling, peer support groups being researched for milder cases • Hormone (still experimental)

18. Postpartum Psychosis • Is the most rare and severe form of postpartum psychiatric illness • Affects 1 – 2 per 1000 deliveries (0.01-0.02%) • Onset of symptoms rapid – often first 72 hours after birth • Majority of cases occur within first 2 weeks postpartum

19. Clinical Presentation • Depressed or elated mood which can fluctuate rapidly (‘kaleidoscopic’) • Disorganized behavior • Mood lability • Confusion • Hallucinations and delusions (religious, visual, misidentification) • Most cases are manic or mixed presentations

20. Diagnoses • Most cases of PP meet criteria for mania, schizoaffective disorders or depression with psychotic features • Long-term outcome shows diagnostic stability • Hospitalization nearly always required • Although rare, risk of suicide and infanticide – suicide is leading cause of maternal death in the UK (Oates, 2003) • Infanticide – delusions or neglect

21. Link between PP & BP • Baseline risk of 1 in 1000 • Jones & Craddock (2001) found rate in women with bipolar disorder was 260 / 1000 deliveries • Rates for women with bipolar disorder who also had a family history of puerperal psychosis was 570 / 1000 deliveries. • Evidence for familiality or heritability

22. Risk of Postpartum Recurrence • 54/103 (52%) women had further children • 31/54 or 57%(95% CI 44–69%) had a further episode of PP • Not significantly associated with previous history or family history of illness • Robertson E et al., Risk of puerperal and non-puerperal recurrence of illness following bipolar affective puerperal (post-partum) psychosis. British Journal of Psychiatry, 2005, 186; 258-259.

23. Risk of Recurrence Unrelated to Childbirth • 62% (64/103) (95%CI 52-71%) experienced a non-puerperal episode • So women were at higher risk of experiencing an episode of illness unrelated to childbirth (62% versus 57%)

24. Between Subjects Comparison Model would have predicted 88% of PP Deliveries using these two variables.

25. Within Subjects Design • Using women as their own controls, compared deliveries from the same women • Delivery complications were significantly associated with episodes of puerperal psychosis ( 2 =5.82, df=1, p=0.016). • No significant associations with developing puerperal psychosis were found for pregnancy complications ( 2 = 0.25. df=1, p=0.62), gestation period (Z= -0.92, p<0.35), gender of the baby ( 2 = 0.53, df = 1, p < 0.25) or Caesarean section ( 2 = 1.29, df = 1, p < 0.25). • Robertson Blackmore et al (2005) Obstetric factors associated with bipolar affective puerperal (postpartum) psychosis.British Journal of Psychiatry, 2006; 188: 32-36.

26. Overall Conclusions • PP is a rare but devastating illness which has long-term effects on the mother and her family. • Risk factors include first delivery, experiencing delivery complications, having a family history of BP, and a family history of PP. • Issues for mom include decision making for further pregnancies, risk of non-puerperal episodes • Research needed to elucidate nature of postpartum trigger

27. Summary • Consultation prior to pregnancy is best • Women with known risk factors should be considered higher risk • Treatment as for non-puerperal episodes • Childbirth related onset of illness common • Risks of further illness need to be discussed