Postpartum Depression and Other Pregnancy-Related Anxiety and Depressive Disorders

1. Postpartum Depression andOther Pregnancy-Related Anxietyand Depressive Disorders Opportunities to Integrate MentalHealth Care Into Medical Practice Bruce E. Kline, PsyD & Associates Kettering, Ohio May 19, 2010

2. Incidence of Postpartum Depression An analysis by O’Hara and Swain (1996) of 59 different studies reported the pooled incidence of 13% postpartum depression in the first six weeks.

3. Contributing Factors for Postpartum Depression • Previous miscarriage/pregnancy loss • Difficult/problematic pregnancy • History of depression and/or anxiety • Fertility treatments • History of abuse • Stressful events in everyday life • Insufficient support system Creedy et al, 2000

4. Symptoms of Postpartum Depression (PPD) • Loss of appetite • Insomnia • Intense irritability and anger • Overwhelming fatigue • Loss of interest in sex • Lack of joy in life • Feelings of shame, guilt or inadequacy • Severe mood swings • Difficulty bonding with the baby • Withdrawal from family and friends • Thoughts of harming self or the baby Mayo Clinic, 2008

5. Other Emotional and Psychological Issues A Massachusetts General Hospital Center for Women’s Mental Health review of the data reported that, - 6% of postpartum women report clinically significant post-traumatic stress disorder symptoms at six weeks postpartum. - 14.9% of postpartum women atsix months reported PTSD symptoms. The review goes on to say that the strongest predictor of PTSD is late pregnancy anxiety with other predictors including psychiatric symptoms in late pregnancy, stressful life events, and the delivery experience. It is interesting to note that the incidence of reported PTSD symptoms actually increases from six weeks to six months postpartum. Possible explanations: other stressors such as lack of sleep, etc. and incompletely processed birth experiences.

6. Post-Traumatic Stress Disorder (PTSD) May be: • Acute: Onset at less than three months • Chronic: Onset at 3-6 months • Delayed: Onset after six months(DSM IV)

7. Post-Traumatic Stress Disorder Incidence The world-wide rate for pregnancy-related PTSD is 2-3% (Adewuya et al, 2006). Subsyndromal postpartum PTSD (women who don’t develop full-blown PTSD but do develop several symptoms of the disorder) rates in Western countries are reported at ~ 30%(Maggioni et al, 2006; Soet et al, 2003; Creedy et al, 2000).

8. What is the Definition of “Traumatic?” The definition of “traumatic” is subjective. There is no definition or guideline of what experiences will triggerpost-traumatic stress symptoms. Two literature reviews do, however, identify several common risk factors for developing postpartum PTSD (Bailham & Joseph, 2003; Olde et al, 2006).

9. Common Risk Factors for PTSD Bailham & Joseph (2003) and Olde et al (2006) identify several common risk factors for developing postpartum PTSD. These include: • Premature births or miscarriages • Difficult deliveries that require instrumental interventions • Emergency c-sections • Feelings of fear for well-being of babies or for themselves • A history of other traumatic experiences, such as sexual abuse • A history of psychological problems or trait anxiety • Insufficient social support from partners and/or staff

10. Early Intervention for PTSD According to the Mayo Clinic, getting treatment as soon as possible after post-traumatic stress disorder symptoms develop may prevent PTSD from becoming a long-term condition (2008).

11. Long-Term Consequences of PP PTSD “The long-term consequences of PTSD after childbirth can be devastating for the mother and/or her family” (Petrillo, 2008). - Nightmares years after trigger event - Poor initiation of breastfeeding - Impaired bonding with the baby - Difficult sexual relations with partner - Feelings of low self-worth - Avoidance of, or fear of, future pregnancies - Impaired relations with older children, partner, and extended family and friends (Zaers et al, 2008; Ilard et al, 1995)

12. Maternal Depression Does Not Just Affect the Mother “The association between maternal depression during pregnancy and risk of antisocial behavior [of children] remained relatively constant in analyses controlling for family environment, a child’s exposure to maternal depression after birth, mothers’ substance use during pregnancy, and parental antisocial behavior” (Hay et al, 2009).

13. The Bottom Line If the patient’s life is being impacted, e.g., her symptoms are interfering with her day-to-day functioning, she needs professional mental health care. Note that any of this range of disorders may appear at any point during the natal year and up to one year postpartum.

14. Standardized Instruments of Measure for Identifying Those at Risk Standardized instruments of measure: • Edinburgh Postnatal Depression Scale • PDSS by Beck & Gable • MGH Three-Question Screening Tool • Kline & Associates Questionnaire

16. PDSSBeck & Gable

17. MGH Three-Question Screening Tool

18. Kline & Associates Questionnaire

19. What Can Care Providers Do to Promote Psycho-Emotional Health? • Become familiar with the predisposing factors and symptoms of depression and anxiety disorders. • Make it a practice to treat patients as partners in their own health care. • Set up integrated protocols for identifying and managing at-risk patients.

20. Become Familiar With Predisposing Factors and Symptoms of Depression and Anxiety Disorders • “Baby blues” • Prenatal depression • Postnatal depression (PPD) • Postpartum Psychosis • Post-Traumatic Stress Disorder

21. Treat Patients as Partners in TheirOwn Health Care All of the interactions women have during the natal year are important to their overall psycho-emotional health. Interactions with care providers particularly offer opportunities for promoting mental and emotional health. Studies show that women in the childbearing year are especially labile and open to suggestion - both positive and negative. These same studies are clear that women who feel more in control and more involved in decision making about their health care, are less likelyto suffer from depression or anxiety postpartum (Childbirth Connection, 2007; Harris Interactive, 2002; Langer et al, 1998; Petrillo, 2008; Waldenstrom & Rudman, 2008). “As a physician, I hope that we can learn to more actively engage our patients in their own care.” - Tricia Pil, Physician and PPD sufferer

22. Four Models for Managing At-Risk Patients • Maintain current status Issues with this model may include: - At-risk patients may not be identified - There may be no established protocol for those who areidentified - Higher potential for untreated depressive and/or anxiety disorders - Risk management concerns

23. 2. Maintain current status with addition of appropriate referrals. Quality referrals include listings of trained psychologists, psychiatrists, therapists, community-based support groups, counselors, etc. Issues with this model may include: • Low patient compliance • at-risk patients may not be proactive • embarrassment factor • underestimating seriousness of issue • Lack of documentation after referral is made • Lack of follow-through

24. 3. Integrate a minimal screening process with quality referrals and follow-up by staff member. Benefits of this model may include: • Increased patient compliance • Improved patient satisfaction • Provides systematic response to positive screening • Minimal documentation with higher return regarding risk management

25. 4. Mental health professional integrated into medical practice. Benefits of this model include: • 85-90% patient compliance • High patient satisfaction • Knowledge that appropriate patient mental health care will be established • System is integrated and protocols are simple and automatic • Ahead of the curve as the medical model begins to move toward whole- person health care • Significantly reduced risk

26. Movement Toward Integration ofMental Health into Medical Practice • New Jersey in 2006 passed a law requiring women to be screened for risk of depression after being discharged following childbirth, as well as at the first postpartum doctor's visit. • Other states, including Illinois and Texas, have passed laws to increase educational awareness of postpartum mental conditions (National Partnership for Women & Families, 2007).

27. Movement Toward the “Hallway Handoff” “According to Cummings (former president of the American Psychological Association), foremost is the need for outreach to the high utilizers of medical/surgical services that translate emotional and psychological issues into baffling physical symptoms that the system spends enormous amounts of healthcare dollars trying to treat medically. … because only a minority of these high utilizers ever follows through on mental health treatment, if behaviorally trained psychologists are co-located in the primary care setting and working side by side with physicians who can make a “hallway handoff” to the trained clinician, 85-90% of these patients will go into treatment, thus reducing medical/ surgical costs by 15%” (Hartman-Stein, 2010).

28. Benefits of Integrated Model • 85-90% patient compliance • High patient satisfaction • Knowledge that appropriate patient mental health care will be established • System is integrated and protocols are simple and automatic • Ahead of the curve as the medical model begins to move toward whole-person health care • Significantly reduced risk

29. References Bailham, D. and Joseph, S. (2003). Post-traumatic stress following childbirth: a review of the emerging literature and directions for future research. Pyschology, Health, and Medicine. 8:159-168. Creedy, D.K., Shochet, I.M., Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: Incidence and contributing factors. Birth. 27(2):104-111. Fatouye, F.O., Oladimeji, B.Y., Adeyemi, A.B. (2006). Difficult delivery and some selected factors as predictors of early postpartum and psychological symptoms. J Psychosom Res. 60(3): 299-301. Gamble, J., Creedy, D., Moyle, W., Webster, J., McAllister, M., Dickson, P. (2005). Hartman-Stein, P.E. (2010). Mental health ‘carve-outs’ sue to block parity. The National Psychologist. Vol. 19, No. 3, Page 1. Hay, D.F., Cardiff University, Pawlby, S., Kings College, London, Angold, A., Duke University, Harold, G.T., Cardiff University and Sharp, D, University of Bristol (2009). Pathways to violence in the children of mothers who were depressed postpartum. Developmental Psychology. Vol. 39, No. 6. Langer, A., Campero, L., Garcia, C., and Reynoso, S. (1998). Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’ wellbeing in a Mexican public hospital: a randomised clinical trial. Br J Obstet Gynaecol. 105(10):1056-63.

30. Maggioni, C., Margola, D., Filippi, F. (2006). PTSD, risk factors, and expectations among women having a baby: A two-wave longitudinal study. J Psychosom Obstet Gynaecol. 27(2), 81-90. Mayo Clinic (2008). Postpartum depression. Available at http://www.mayoclinic.com/health/postpartum-depression/DS00546/DSECTION=symptoms O'Hara, M.W., Swain ,A.M. (1996). Rates and risk of postpartum depression: A meta-analysis. Int Rev Psychiatry. 8:37-54. Olde, E., van der Hart, O., Kleber, R., and van Son, M. (2006). Posttraumatic stress following childbirth: A review. Clinical Psychology Review 26:1-16. Petrillo, L. (2008). Post-traumatic stress disorder (PTSD) following childbirth. MGH Center for Women’s Mental Health/Harvard Medical School. Available at http://www.womensmentalhealth.org/posts/post-traumatic-stress-disorder-ptsd-following-childbirth/ Zaers, S., Waschke, M., Ehlert, U. (2008). Depressive symptoms and symptoms of post-traumatic stress disorder in women after chilbirth. J Psychosom Obstet Gynaecol. 29(1):61-71. © 2010 Bruce E. Kline & Associates Information in this presentation is for educational purposes only.