POSTPARTUM DEPRESSION BEYOND THE BLUES Debby Carapezza R

POSTPARTUM DEPRESSION BEYOND THE BLUES Debby Carapezza, R. N. , M. . S. N. Nurse Consultant, Reproductive Health Program Utah Department of Health

INCIDENCE OF DEPRESSION § Each year, 15% to 20% of adults in the United States experience a major depression § The incidence among women is twice that of men and peaks between 18 to 44 years of age - the childbearing years

DEPRESSION IN WOMEN § Women are at increased risk of mood disorders during periods of hormonal fluctuationl l l premenstrual postpartum perimenopausal

THE RANGE OF POSTDELIVERY MOOD DISORDERS § 50% to 80% of women experience transient “baby blues” within the first two weeks following delivery § 0. 1% to 0. 2% of women experience postpartum psychosis usually within the first 4 weeks following delivery

POSTPARTUM DEPRESSION § 6. 8% to 16. 5% of women experience postpartum depression (PPD) also known as postpartum major depression (PMD) § Onset can be as early as 24 hours or as late as several months following delivery

SYMPTOMS OF POSTPARTUM DEPRESSION

RANGE OF SYMPTOMS § Symptoms rangel l l from mild dysphoria to suicidal ideation to psychotic depression

DURATION OF SYMPTOMS § Untreated, symptoms can last: l several months l into the second year postpartum

THE ETIOLOGY OF POSTPARTUM DEPRESSION § Various theories based in physiological changes have been postulated: l hormonal excesses or deficiencies of estrogen, progesterone, prolactin, thyroxine, tryptophan, among others

ETIOLOGY OF POSTPARTUM DEPRESSION § Other theories cite numerous psychosocial factors associated with PMD: l l marital conflict child-care difficulties (feeding, sleeping, health problems) perception by mother of an infant with a difficult temperament history of family or personal depression

POSTPARTUM DEPRESSION IN UTAH What can PRAMS data tell us?

INDICDENCE OF POSTPARTUM DEPRESSION AMONG 2000 UTAH PRAMS RESPONDENTS § 24. 1% of PRAMS respondents indicated that in the months after delivery they were moderately to very depressed

§ When the results of the survey are weighted to represent all 47, 331 Utah women who had a live birth in 2000, this means an estimated 11, 416 women reported being moderately or very depressed.

Higher rates of depression were noted among women who:

THE IMPACT OF POSTPARTUM DEPRESSION

LONG TERM CONSEQUENCES OF PMD § Negative impact on the infant ‘s social, emotional and cognitive development l 2 month old infants of mothers with PMD had decreased cognitive ability and expressed more negative emotions during testing

LONG TERM CONSEQUENCES OF PMD § Babies of mothers with PMD were perceived by their mothers as more difficult to care for and more bothersome.

POSTPARTUM DEPRESSION & MATERNAL MORTALITY IN UTAH § In recent years, there have been two maternal deaths due to suicide by women within one year of giving birth. § Neither woman had been screened for postpartum depression

RISK FACTORS FOR PMD

INTERVENTIONS SCREENING FOR PMD

SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: § Be unable to recognize she is depressed

SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: § Believe her symptoms are “normal” for new moms

SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: § Fear being labeled a “bad mother” if she admits her maternal experience does not meet society’s picture of bliss

SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: § Feel she is going crazy and fears her baby will be taken from her

WHEN TO SCREEN FOR PMD § § § § At preconception visit During prenatal intake & subsequent visits During postpartum exams During infant’s WCC & WIC visits When infant is seen for sick care or in ER At early intervention home visits At family planning visits during the first year postpartum § At mother’s visits for routine episodic care

SCREENING TOOLS § There are several tools available: l l Edinburgh Postnatal Depression Scale (EPDS) The Mills Depression & Anxiety Checklist The Center for Epidemiological Studies Depression Scale (CES-D) Others, often on various websites for mental health

A WORD ABOUT SCREENING TOOLS! § Be familiar with the tool - its validity and limitations § Have a referral network available for women screening positive § Document the screening and any referrals made § Follow-up with your client to assure that she received needed assistance

EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS) § § § Designed for home or outpatient use Consists of 10 questions Can be completed in approx. 5 minutes Reviews feelings the previous 7 days Scored 0 -3 depending on symptom severity Depending on study, cut off is 13 - 9 points

SAMPLE EPDS QUESTIONS § 1. I have been able to laugh & see the funny side of things l l As much as I always could Not quite so much now Definitely not so much not Not at all

SAMPLE EPDS QUESITONS (Cont. ) § *3. I have blamed myself unnecessarily when things went wrong l l Yes, most of the time Yes, some of the time Not very often No never

SAMPLE EPDS QUESTIONS (Cont. ) § *6. Things have been getting on top of me l l Yes, most of the time I haven’t been able to cope at all Yes, sometimes I haven’t been coping as well as usual No, most of the time I have coped as well as ever No, I have been coping as well as ever

TREATMENT § 1. Educate the woman and her support system regarding the diagnosis of postpartum depression.

TREATMENT OPTIONS § Pharmacological intervention § Counseling, individual and/or group § Support groups

PHARMACOLOGICAL INTERVENTION § Use of tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) may be indicated for both nonnursing and nursing mothers § Have low incidence of infant toxicity and adverse effects during breastfeeding* § Decisions regarding use while breastfeeding must be on a case by case basis

OTHER CONSIDERATIONS: § Provider must be familiar with agents and the hepatic function of mother and infant § Client must be informed of risks/benefits of treatment Vs. no treatment for herself and her infant l unknown impact of long-term use of medications on neurodevelopment of infant

Other Considerations - Cont. § If the woman chooses to breastfeed while on psychotropics, she should work collaboratively with a psychiatrist and her pediatrician § If the infant experiences insomnia or other behavior changes, his serum should be assayed for the presence of medication § Document all discussions regarding treatment in the client’s chart

TREATMENT OF DEPRESSION PATIENT ASSISTANCE PROGRAMS § Pharmacological treatment of depression can be effective. Unfortunately, it can also be expensive. Costs of antidepressants vary depending on the drug, dose and pharmacy. § Paxil® 20 mg qd X 30 Days = $85. 39 § Prozac® 20 mg qd X 30 Days = $67. 79 (generic) § Zoloft® 50 mg qd X 30 days = $75. 00 § Elavil®, at approximately 75 mg qd X 30 days = $11. 39 (generic) or $37. 89 (brand).

COUNSELING § Know referral sources in your locale, especially those that: l l accept Medicaid utilize a sliding fee will develop a payment plan with the client offer free counseling § Be familiar with indigent drug programs available through various pharmaceutical manufacturers

Counseling - Cont. § Any woman with symptoms of psychosis or with serious suicidal/homicidal ideation should be referred for emergency psychiatric evaluation

SUPPORT GROUPS § Numerous postpartum support groups are available. Contact: § Local mental health agencies § Hospitals § Websites

WEBSITE INFO & SUPPORT § Depression After Delivery http: //www. depressionafterdelivery. com § Postpartum Support International http: //www. postpartum. net/ § The Postpartum Stress Center http: //www. postpartumstress. com/ § Postpartum Education for Parents http: //www. sbpep. org § Office on Women’s Health http: //www. 4 women. gov-pregnancy-after the baby is born-PPD

Websites and Other Resources § Mental Health Association in Utah l http: //www. xmission. com/~mhaut/ § For information on medication while breastfeeding, call Pregnancy Risk. Line: l l In Salt Lake City: 328 -BABY (2229) Outside Salt Lake: 1 -800 -822 -BABY (2229)

SUMMARY § Postpartum depression: l l l is relatively common may have long-term consequences for mother, infant & family is easily missed should be screened for can be treated successfully