Depression in Pregnancy

1. 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

2. 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)

3. 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)

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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)

14. 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

15. 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

16. 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)

17. 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

18. 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)

19. 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)

20. 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)

21. 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)

22. 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)

23. 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)

24. 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)

25. 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)

26. 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)

27. 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)

28. 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)

29. Depressed pregnant women are underdiagnosed and undertreated (American Psychiatric Association Meeting, 2004)

30. Pregnancy is a time of increased contact with health services Chance for the early identification and intervention of depression

31. 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

32. 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)

33. 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)

34. 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

35. 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

36. 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)

37. 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

38. 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)

39. 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).

40. 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

41. 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

42. Thank you Women and Staff… Healthy Mother Healthy Baby, Community and Westside Clinic, Postpartum Depression Support Program, Saskatoon. SK, Canada