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Obstetrics > Perinatal and Postpartum Depression > Flashcards

Perinatal and Postpartum Depression Flashcards

1
Q

perinatal depression prevalence

A
  • Prevalence of Major Depression in Adults
    • Depression is a common, debilitating condition
    • The National Comorbidity study documented a lifetime prevalence in individuals between the ages of 15 – 54 at 17.1%
    • Depression also documented to be more prevalent in women, and occurring most often between the ages of 18 – 59
  • Major depression during pregnancy
    • 9.4 – 12.7%
  • Major depression postpartum
    • 7.1% in first 3 months
    • 21.9% in first 12 months
  • 25%-30% of women with history of MDD are at risk for postpartum depression
  • By comparison:
    • 2-10% have gestational diabetes
    • 5-8% have hypertension in pregnancy
  • According to the Centers for Disease Control, 11 to 20% of women who give birth each year have postpartum depression symptoms. If you settled on an average of 15% of four million live births in the US annually, this would mean approximately 600,000 women get PPD each year in the United States alone.
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2
Q

postpartum blues

A
  • Features: tearfulness, lability, reactivity
  • Predominant mood: happiness
  • Peaks 3-5 days after delivery
  • Present in 50-80% of women
  • Present in all cultures studied
  • Unrelated to environmental stressors
  • Unrelated to psychiatric history
  • Common for women to feel this after their baby’s birth, but for 1 in 7 women this progresses to more serious mood disorder of PPD
  • 2018- estimated 85% of women experience some type of mood disturbance in postpartum period, 10-15% will experience more disabling and persistent form of depression, .1-.2% experience PP psychosis
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3
Q

hormone withdrawal hypotheses

A
  • Estrogen
    • Receptors concentrated in the brain
    • “Blues” correlate with magnitude of drop
  • Progesterone metabolite (allopregnanolone)
    • GABA agonists; CNS GABA levels & sensitivity may decrease during pregnancy as an adaptation
    • The reduced brain GABA may recover more slowly in women with “blues”
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4
Q

oxytocin as a neuropeptide neurotransmitter

A
  • Peripheral effects include uterine contraction and milk ejection
  • Receptors concentrated in brain
  • New receptors are induced by estrogen during pregnancy
    • Social attachment/ bonding
    • Pair-bonding/ intimacy
    • Parental behavior
  • Disruption prevents/decreases maternal behavior
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5
Q

posited relationships between the “blues” and postpartum depression

A
  • A subset of women may be vulnerable to mood disorders at times of hormonal flux (premenstrual, postpartum, perimenopausal) regardless of environmental stress
  • The normal heightened emotional responsiveness caused by oxytocin may predispose to depression in the context of high stress and low social support
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6
Q

major depression: key symptoms

A
  • At least one of the following (by self-report or others’ observations) for 2 weeks
    • Depressed mood most of the day, nearly every day
    • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
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7
Q

major depression: associated symptoms

A
  • Four or more of the following:
    • Changes in weight and appetite
    • Insomnia or hypersomnia
    • Psychomotor agitation or retardation
    • Fatigue or loss of energy
    • Feeling worthless or guilty
    • Impaired concentration, indecisiveness
    • Thoughts of death
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8
Q

clinical features of postpartum depression

A
  • Depressed, despondent and/or emotionally numb
  • Sleep disturbance, fatigue, irritability
  • Loss of appetite
  • Poor concentration
  • Feelings of inadequacy
  • Ego-dystonic thoughts of harming the baby
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9
Q

confounds in diagnosing depression during pregnancy

A
  • Overlapping symptoms
    • Sleep disturbance
    • Increased appetite
    • Decreased energy
    • Changes in concentration
  • Illnesses with similar symptoms
    • Anemia
    • Thyroid dysfunction
    • Gestational diabetes mellitus
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10
Q

characteristics of postpartum depression

A
  • Begins within 4 weeks of birth
    • by DSM-IV definition
  • Clinical presentation peaks 3-6 months after delivery
  • Postpartum period considered up to 1 year
  • Related to environmental stressors
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11
Q

cultural context of postpartum depression

A
  • Regardless of culture, the risks of postpartum depression are similar
    • Previous episodes of depression
    • Significant loss or life stress
    • Unwanted/ unplanned pregnancy
    • Prior fetal loss
    • Unexpected birth outcomes
    • Marital conflict
    • Socioeconomic status
    • Low social support
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12
Q

postpartum psychoses

A
  • Heterogeneous group of disorders
    • Bipolar disorder
    • Major depression with psychotic features
    • Schizophrenia spectrum disorders
    • Medical conditions (e.g. thyroid disease, low B12)
    • Drugs (e.g. amphetamines, hallucinogens, bromocriptine)
  • Prevalence
    • 1-2 per 1,000 women giving birth
    • About 35% of women with bipolar diathesis
  • Onset usually within 3 weeks postpartum
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13
Q

postpartum psychoses symptoms

A
  • Delusions (e.g. baby is possessed by a demon)
  • Hallucinations (e.g. seeing someone else’s face instead of baby’s face)
  • Insomnia
  • Confusion/disorientation (more than non-postpartum psychoses)
  • Rapid mood swings (more than non-postpartum psychoses)
  • Waxing and waning (can appear and feel normal for stretches of time between psychotic symptoms)
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14
Q

factors that may contribute to risks associated with antenatal depression

A
  • Indirect effects
    • Reduced prenatal care
    • Less optimal nutrition
  • Poor appetite and weight loss
    • Socioeconomic deprivation
    • Increased use of cigarettes and alcohol
  • Direct effects
    • Changes in cortisol & HPA axis development
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15
Q

effects of untreated depression on obstetric complications

A
  • Low birth weight
  • Premature birth
  • Pre-eclampsia
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16
Q

effects of antenatal depression on offspring

A
  • Newborns cry excessively and are more inconsolable
  • Babies (up to age 1) have poorer growth and increased risk of infection
  • Children (up to age 5) have more difficult temperaments, more distress, sadness, fear, shyness, frustration
17
Q

early consequences of untreated postpartum depression for offspring

A
  • Sometimes none
  • Disturbed mother-infant relationship
  • Cortisol elevation (baby and mother)
  • Failure to thrive
  • Physical injury/death
18
Q

later consequences of prolonged maternal depression for offspring

A
  • Depression
  • Behavioral disturbance, including conduct disorder
  • Reduced cognitive abilities
  • More school problems (truancy, dropping out)
  • Role reversal
19
Q

effects of maternal stress and anxiety during pregnancy

A
  • Altered fetal hemodynamics and movement
  • Lower gestational age
  • Lower infant birth weight
  • Lower Apgar scores
  • Enduring changes in cortisol measures in offspring – so far observed up to age 10
20
Q

potential effects of postpartum depression on relationships

A
  • Altered roles within the couple
  • Altered roles within the extended family
  • Establishing alternate caregiver patterns that become difficult to change later
  • Impaired communication
  • Psychiatric symptoms in the partner
21
Q

risk of suicide from untreated major depression during pregnancy

A
  • Overall risk may be lower than in non-pregnant women
  • Risk may be increased when:
    • Pregnancy is unwanted, especially when woman wanted an abortion but could not obtain one
    • Partner abandoned woman during pregnancy
    • Woman has had prior pregnancy loss and/or death of children
22
Q

infanticide due to postaprtum depression

A
  • Rare; greater risk with psychotic symptoms
  • Rarely has a history of abusing children
  • Most often part of a suicide attempt
  • No anger toward baby; wish not to abandon baby and/or not to burden others with baby
  • Rarely attempt to conceal; often self-report
23
Q

thoughts of harming baby: low risk

A
  • Common in non-psychotic PPD – 41% of depressed mothers vs 7% of controls
  • Mother doesn’t want to harm baby
  • Thoughts are ego-dystonic (obsessive in nature & odd/frightening to mother)
  • Mother has taken steps to protect baby
  • Mother has no delusions or hallucinations related to harming baby
24
Q

thoughts of harming baby: high risk

A
  • Mother has delusional beliefs about the baby
    • e.g. that the baby is a demon
  • Thoughts of harming baby are ego-syntonic
    • mother thinks they are reasonable and/or feels tempted to act on them
  • Mother has a history of violence
  • Mother has labile mood and/or impulsive behavior
25
Q

potential effects on the mother-infant relationship

A
  • Brain and Central Nervous System Development
    • Interplay between genes and experiences
    • Early interactions directly affect how the brain is “wired”
    • HPA axis – stress response system impact
  • Attachment
    • Infants of depressed mothers are at high risk for developing an insecure attachment
    • Relational problems between infants and their caregivers are connected to early social, emotional, and behavioral problems for children
26
Q

the importance of early relationships

A
  • Transactional model of infant-caregiver relationships
    • Both infants and caregivers contribute to the developing relationship based on their own unique characteristics (temperament, neurology, etc.) and the context through mutually interactive transactions
  • Attachment Theory: Impact on Development
    • Secure attachment = child views the caretaker as loving and responsive, and her/himself worthy of love
    • Insecure attachment = child views caretaker as unresponsive (possibly rejecting) and her/himself unworthy of love
    • Insecurely attached child at risk for later behavior disorders, mood disorders, and delayed cognitive development
27
Q

transactional model: building a relationship is a two way street

A
  • The infant brings to the relationship:
    • Readiness to socially interact with others
    • Unique constellation of individual characteristics & temperament
    • Inherent drive towards mastery
    • Resilience
  • The parent brings to the relationship:
    • The capacity to recognize and respond to the infant’s emotional signals (sensitivity & responsiveness)
    • Current mental and physical status
    • Social support network
    • A history of being in other relationships
    • Screening and Assessment
28
Q

detecting perinatal depression: why screen?

A
  • High prevalence rate
  • Risks of untreated symptoms
  • Availability of effective treatments
  • Under-detection by routine clinical evaluation
  • Availability of validated screening tools
29
Q

screening for peripartum depression

A
  • Edinburgh Postnatal Depression Scale (EPDS)
    • 10 item self-report questionnaire
    • Advantages:
      • Easy to score
      • Specifically designed for peripartum use
      • Well validated during pregnancy and postpartum
      • Cross-culturally validated; available in over 20 languages
    • Disadvantages:
      • Not linked with DSM-IV diagnostic criteria
      • Cannot be used for assessment or treatment tracking
  • Patient Health Questionnaire (PHQ-9)
  • 9-item self-report questionnaire
  • Advantages:
    • Easy to score
    • Items & scores linked to DSM-IV depression criteria
    • Can use to assess & track treatment response
    • Can use same tool for non-peripartum patients in clinic
  • Disadvantages:
    • Not designed for peripartum use (somatic confounds)
    • Not as well validated peripartum (2 studies)
30
Q

interpretation of the EPDS

A
  • Maximum score: 30
  • Always look at item 10 [suicidal thoughts]
  • Sensitivity and specificity vary according to the chosen cut-off score
    • Validated cut off score of 10-13
  • Use an assessment tool to further evaluate women with high scores
  • Example: Aiming for a sensitivity of at least 0.8 and a specificity of at least 0.7 in detecting peripartum major depression
    • Cut-off scores between 10 and 12 have consistently yielded sensitivity and specificity scores in that range
    • Cut-off scores above 12 have not been sensitive enough in some studies
31
Q

PHQ-9 scoring

A
  • Total score ranges from 0 – 27
  • A score of 5 or above out of 27 is considered positive
  • Each numeric value is directly linked to the DSM-IV diagnostic criteria for major depression, including severity criteria
  • Subtotal each of the 3 columns and add together to determine the total score
  • Score tells whether woman meet DSM-IV criteria for major depressive episode along with severity level
    • 0 - 5: does not meet criteria for major depression
    • 5 - 9: mild depression
    • 10 - 14: moderate depression
    • 15 - 19: moderately severe depression
    • 20 - 27: severe depression
  • Initial treatment response: drop in score of 5 or more from pre-treatment baseline after 4 weeks of treatment
  • Adequate treatment response: 50% decrease in score after 8 weeks of treatment
  • Remission: post-treatment score < 5
  • If response in primary care setting is inadequate, refer for mental health care
32
Q

summary of validated screening tools

A
  • EPDS
    • Best validated screening for peripartum populations
  • PHQ-9
    • Best validated for tracking response to treatment
33
Q

other tools sometimes used for perinatal depression screening

A
  • Beck Depression Inventory
    • 3 postpartum validation studies
  • Center for Epidemiologic Studies – Depression
    • 1 postpartum validation study
  • Postpartum Depression Screening Scale
    • 2 postpartum validation studies; longer than other screens
34
Q

treatment options

A
  • Psychopharmacology
    • Antidepressants
    • Anxiolitics
    • Antipsychotics
  • Psychotherapy
    • Interpersonal
    • Cognitive-behavioral
    • Couples/Family
    • Mother-Infant didactic
35
Q

the role of social support

A
  • The quality of relationships directly impacts mental health:
    • Encouragement – to follow through on self care and other tasks to promote health
    • Sense of belonging – increases self-esteem and sense of purpose
    • Calming/Soothing – the knowledge that someone is there if needed
    • Enjoyment – pleasurable experiences with others (even if temporary)
36
Q

evidence of protective influences of social support

A
  • Receiving adequate social support during the early parenting period is associated with:
    • Greater satisfaction with the marital relationship
    • Better maternal-child interactions
    • Decreased incidence of postpartum depression
    • Increased rate of maternal education completion
  • Less maternal alcohol and drug use
  • Higher rates of obtaining timely infant immunizations
  • Fewer unintentional infant injuries
  • Decreased incidence of child abuse
37
Q

recruiting social support

A
  • Examples of places people often find support
    • Partner
    • Family & Extended family
    • Neighbors
    • Co-workers
    • Religious communities
    • Professionals (doulas, lactation consultants, etc)
    • Postpartum support groups
    • Family community agencies
38
Q

educate about self-care

A
  • Social support
  • Sleep
  • Breaks from baby
  • Enjoyable, replenishing activities
  • Nutrition (iron, calcium, folate, EFA’s)
  • Aerobic exercise
  • Break isolation
    • Be with friends, partner, and/or other mothers with or without baby
  • Take time for yourself (even if only 5 minutes)
  • Protect yourself and your energy
    • Turn off phones, limit visitors, eat frozen food, etc.

Obstetrics (14 decks)

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