By

Slide 1:ByRicardo J. Fernandez, M.D., DFAPACouncilor, NJ Psychiatric Association

Slide 2:�Postpartum Depression�Psychiatric Syndromes of the Postpartum Period

Slide 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.

Slide 4:Women are at serious risk for developing a psychiatric illness after childbirth.

D. Wolocko, Daily News

Slide 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.

Slide 6: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.

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

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

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

Slide 10:The four syndromes are:

Maternity or Postpartum Blues Postpartum Psychosis Adjustment Disorder of the Postpartum Period Major Depression in the Postpartum (Postpartum Depression)

Slide 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.

Slide 12:Spectrum of Postpartum Mood Changes

Incidence Key Point The spectrum of postpartum mood disturbances ranges from the transient, relatively benign postpartum blues to major depression during the postpartum period to postpartum psychosis, which is considered a medical emergency Background Postpartum blues is the most frequently observed postpartum mood disturbance. Symptoms are generally transient and nonpathologic, however the presence of blues may herald the development of major depression in some patients Depression during the postpartum period affects approximately 10% of patients, which is not greater than the risk for depression at other time points in a woman�s life The signs and symptoms of depression during the postpartum period are essentially indistinguishable from MDD during other times in a woman�s life (e.g., depressed mood, anhedonia, feelings of guilt, decreased energy, etc). Thus, the diagnosis of postpartum depression is not distinct from a diagnosis of a major depressive episode at another time period.1 The DSM-IV postpartum onset specifier for MDD2 is restricted to episodes with an onset within 4 weeks of delivery; however, some women develop symptoms more insidiously weeks or even months later Left untreated, depression in the postpartum period is associated with health risks to the mother as well as the child, in terms of cognitive, emotional, and social development Postpartum psychosis, the most severe form of postpartum psychiatric illness, is a rare condition that is considered a medical emergency when it develops. It typically has a dramatic onset and is characterized by psychotic symptoms, disorientation, and disorganized behavior. Patients exhibit manic, depressive, or mixed feelings (often with rapidly shifting mood), and it is associated with considerable dysfunction. As with depression in the postpartum period, postpartum psychosis is not a discreet diagnosis separate from psychotic episodes at other time periods.1 The DSM-IV postpartum specifier2 would be applicable if onset was within 4 weeks of delivery, and it would be used to modify a diagnosis of Mood Disorder With Psychotic Features, Brief Psychotic Disorder, Psychotic Disorder Due to a General Medical Condition, Substance-Induced Psychotic Disorder, or Postpartum Psychosis Not Otherwise Specified Other preexisting psychiatric disorders may be exacerbated during the postpartum period as well (e.g., OCD) Reference 1. Cohen LS. Depress Anxiety. 1998:1:18-26. 2. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.Key Point The spectrum of postpartum mood disturbances ranges from the transient, relatively benign postpartum blues to major depression during the postpartum period to postpartum psychosis, which is considered a medical emergency Background Postpartum blues is the most frequently observed postpartum mood disturbance. Symptoms are generally transient and nonpathologic, however the presence of blues may herald the development of major depression in some patients Depression during the postpartum period affects approximately 10% of patients, which is not greater than the risk for depression at other time points in a woman�s life The signs and symptoms of depression during the postpartum period are essentially indistinguishable from MDD during other times in a woman�s life (e.g., depressed mood, anhedonia, feelings of guilt, decreased energy, etc). Thus, the diagnosis of postpartum depression is not distinct from a diagnosis of a major depressive episode at another time period.1 The DSM-IV postpartum onset specifier for MDD2 is restricted to episodes with an onset within 4 weeks of delivery; however, some women develop symptoms more insidiously weeks or even months later Left untreated, depression in the postpartum period is associated with health risks to the mother as well as the child, in terms of cognitive, emotional, and social development Postpartum psychosis, the most severe form of postpartum psychiatric illness, is a rare condition that is considered a medical emergency when it develops. It typically has a dramatic onset and is characterized by psychotic symptoms, disorientation, and disorganized behavior. Patients exhibit manic, depressive, or mixed feelings (often with rapidly shifting mood), and it is associated with considerable dysfunction. As with depression in the postpartum period, postpartum psychosis is not a discreet diagnosis separate from psychotic episodes at other time periods.1 The DSM-IV postpartum specifier2 would be applicable if onset was within 4 weeks of delivery, and it would be used to modify a diagnosis of Mood Disorder With Psychotic Features, Brief Psychotic Disorder, Psychotic Disorder Due to a General Medical Condition, Substance-Induced Psychotic Disorder, or Postpartum Psychosis Not Otherwise Specified Other preexisting psychiatric disorders may be exacerbated during the postpartum period as well (e.g., OCD) Reference 1. Cohen LS. Depress Anxiety. 1998:1:18-26. 2. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

Slide 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.

Slide 14:Now, lets discuss the specific syndromes.

Slide 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

Slide 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.

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

Slide 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

Slide 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

Slide 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.

Slide 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.

Slide 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.

Slide 23:Onset of Symptoms in Postpartum DepressionTwo Studies

2. Time of Onset of Postpartum Depression in 413 Patients The more severe, the earlier the onset.

Slide 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

Slide 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.

Slide 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

Slide 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

Slide 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.

Slide 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

Slide 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

Slide 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.

Slide 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

Slide 33:What about breast feeding?

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

Slide 34:Incidence of Breast Feeding 1926-2001

80% 49% 28% 20% 37% 52% 67% 61% 1926- 1930 1951- 1955 1966- 1970 1972 1975 1998 2000 2001 Briggs, Freeman, Yafee, Drugs in Pregnancy and Lactation, 1998 Maternity Survey, Parents Express, Phil.,PA., 4/01, 4/02 From Drugs in Pregnancy and Lactation,Fifth edition.Briggs,Freeman,and Yafee, Williams and Witlkins.Md.1998.From Drugs in Pregnancy and Lactation,Fifth edition.Briggs,Freeman,and Yafee, Williams and Witlkins.Md.1998.

Slide 35:�a reasonable optionin Postpartum Depression ?

Breast feeding�

Slide 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.

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

Slide 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

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

Slide 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.

Slide 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