According to Agency for Healthcare Research and Quality, depression is the leading cause of disease related disability among women. Point prevalence of major depressive disorder in women is 5-9% with lifetime risk of 10-25%
Pregnancy related mood disorders bridge a range of conditions which vary in onset and severity. These include…. Postpartum depression occurs in as many as 1 in 8 US pregnancies. More common than gestational diabetes, preeclampsia or preterm delivery.
Transient condition
Transient condition
Fatigue, being overwhelmed common symptoms of depression and often seen in new mothers.
Usually a psychiatric emergency and will require hospitalization
Each of which has been shown to be a predictor of poorer fetal outcome.
Significant risk factors for development of postnatal depression in men include depression in partner during or shortly after pregnancy and personal h/o depression
Major depressive disorder in women 5 – 9% Lifetime risk is 10 – 25% Prevalence depends on assessment method, timing of assessment, and population characteristics. Prevalence of postpartum depression is close to that in nonpregnant women, but rate of onset of new episodes of depression is 3x higher than in nonpregnant controls. Postpartum psychosis occurs in 1.1-4 cases/1000 deliveries
AHRQ- major and minor depression 8.5 –11 % during pregnancy and 6.5 – 12.9% during 1 st postpartum year Prevalence of major depression is highest in 2 nd trimester, 2 months postpartum and 6 months postpartum
AHRQ- major and minor depression 8.5 –11 % during pregnancy and 6.5 – 12.9% during 1 st postpartum year Prevalence of major depression is highest in 2 nd trimester, 2 months postpartum and 6 months postpartum
Rate for + depression screen was almost 2x rate reported in nonmilitary populations, both antepartum and postpartum. OF those who screened +, 36% were considered emergent – score >20 or + answer to suicide ideation question. In postpartum period, rate of suicide ideation was triple that observed in 1 study
Most women depressed during pregnancy will remain depressed postpartum Women who conceive less than 12 months after stillbirth are at higher risk of depression in 3 rd trimester of next pregnancy & at 1 year postpartum compared to women who conceive after 12 months
Previous miscarriage- risk of PPD is higher among women with prior h/o depression than in those without h/o depression. Elevated risk is highest in 1 st six months after loss. Women who conceive less than 12 months after stillbirth are at higher risk of depression in 3 rd trimester of next pregnancy & at 1 year postpartum compared to women who conceive after 12 months
Many of these occur in active duty population and dependents
Many of these occur in active duty population and dependents
Sick leave during pregnancy- related to hyperemesis, uterine irritability, psychiatric disorder
One study looked at association of postpartum blues and estrogen withdrawal. Women who developed PPB had a significantly higher level of free estriol at 38 wks and a greater fall of free estriol concentration on postpartum day #1.
One study looked at association of postpartum blues and estrogen withdrawal. Women who developed PPB had a significantly higher level of free estriol at 38 wks and a greater fall of free estriol concentration on postpartum day #1.
AHRQ all screeners (beck depression inventory, postpartum depression screening scale, EPDS) had high specificity for major depression alone. Means the risk of a screen being a false positive is low. EPDS and PDSS more sensitive Looking at major and minor depression together, the sensitivity is much lower
AHRQ all screeners (beck depression inventory, postpartum depression screening scale, EPDS) had high specificity for major depression alone. Means the risk of a screen being a false positive is low. EPDS and PDSS more sensitive Looking at major and minor depression together, the sensitivity is much lower
AHRQ all screeners (beck depression inventory, postpartum depression screening scale, EPDS) had high specificity for major depression alone. Means the risk of a screen being a false positive is low. EPDS and PDSS more sensitive Looking at major and minor depression together, the sensitivity is much lower
Developed in 1987
Compared to spontaneous detection, 35.4 % vs 6.3% AT 6 wk postpartum visit EPDS administration in first few days postpartum can predict maternal mood 4-8 wks later
Insert EPDS from UPTODATE here
DSM IV criteria- 5 or more symptoms for at least 2 wks- depressed mood, fatigue, loss of energy, loss of pleasure or interest, increased sense of worthlessness or guilt, significant weight loss/gain, decreased concentration, insomnia or hypersomnia, recurrent morbid thoughts or suicidal ideations, agitation or retardation, significant distress or impairment of function, not better accounted for by bereavement
DSM IV- uses postpartum onset modifier if occurs in first 4 wks postpartum ICD coding- if occurs in 1 st 6 wks postpartum, ICD code for postpartum depression
British study showed that multiple home visits thru 28 days postpartum in addition to a consult at 10-12 wks had lower EPDS scores than those receiving visits only thru 10-14 days postpartum
AHRQ reviewed 6 studies which showed significant benefit for depression outcomes with psychosocial thearpies Small study which compared women who received 6 sessions of CBT to women receiving fluoxetine showed same degree of improvement in functioning Interpersonal psychotherapy- good in tx of mood and anxiety disorders; effective in decreasing depressive symptoms and increasing social adjustment
Family and marital therapy more rapid recovery for postpartum women more appreciative of partner’s contributions to relationship when partner is supportive
Addresses four main problem domains with respect to human psychosocial functioning One small study of 13 women showed decrease in symptoms and induction of remission in all 13. In the 10 women followed post partum none developed post partum depression
Several studies have shown a non-statistically significant increase in the number of miscarriages in women taking SSRIs or SRNIs – it is not clear if this is secondary to the medications or the depression itself. Two meta-analyses of ssri and tca use during pregnancy failed to show an increase in fetal anomalies. However recently - Swedish Medical birth registry has shown a 1.5 to 2 fold increased risk for cardiovascular malformations (vsd and asd) associated with 1 st trimester exposure to paroxetine Risk of neonatal toxicity of withdrawal syndromes during the acute neonatal period One study showed women who took fluoxetine in the 3 rd trimester had significantly higher rates of preterm delivery and poor neonatal adaptation. In full term infants, the mean birth weight was significantly lower. Fluoxetine is most studied of SSRIs. Could be beneficial in that it has a long half life, so one does not need to taper the dose. Zoloft shows to have one of the lowest levels in breast milk Long term effects on cognitive development and behaviour are unknown.
Seizures have only been seen with clomipramine
Have been seen with both fluoxetine and paroxetine Not clear if SSRIs with longer half lives have same withdraw symptoms
Two studies by nulman of children exposed to either tcas or ssris during pregnancy demonstrated no signficant differences in…..
Need to take into account risks of fetal exposure to medication, potential impact of untreated maternal depression during pregnancy on neonatal outcome and potential risks of neonatal syndromes associated with certain antidepressants.
One study showed there was no difference between nortryptiline and placebo
Small study with transdermal estradiol showed improvement in women with severe and persistent ppd
ECT typically requires 3-9 treatments to produce an effective response. Treatments are 3x/wk Rapid treatment needed = mother at risk for suicide or infanticide In past 50 years there has been only four cases of preterm labor and none of SROM associated with ECT
While a patient’s length of therapy is often based on their history of prior depression, recurrence rate, and severity of previous symptoms, it is often recommended that women continue medications for at least one year following full remission of symptoms. If a patient becomes pregnant while on antidepressants you should continue meds through pregnancy to reduce the risk of relapse. JAMA study in feb 1, 2006- of 201 women with h/o depression, 43% experienced relapse of major depression during pregnancy. Those who maintained meds during pregnancy only had 26% relapse vs 68% in those who stopped meds. 50% relapsed in 1 st trimester and 90% by end of 2 nd trimester Both duration of depressive illness and h/o more recurrent depressive were associated with significant increase in risk of depressive relapse during pregnancy Maintenance of euthymic mood during pregnancy is essential in reducing long term morbidity and mortality
JAMA study in feb 1, 2006- of 201 women with h/o depression, 43% experienced relapse of major depression during pregnancy. Those who maintained meds during pregnancy only had 26% relapse vs 68% in those who stopped meds. 50% relapsed in 1 st trimester and 90% by end of 2 nd trimester Both duration of depressive illness and h/o more recurrent depressive were associated with significant increase in risk of depressive relapse during pregnancy Maintenance of euthymic mood during pregnancy is essential in reducing long term morbidity and mortality
Combination therapy is often required, including mood stabilizers, antipsychotics, benzodiazopines, and antidepressants. Consideration should be given to discontinuing breastfeeding secondary to potential effects of medication combinations of the infant.
Risk of ppd is 25% in women with previous h/o depression and 50% if prior h/o ppd
It is important to screen patients during antepartum visits, while in the hospital and at postpartum and well baby visits
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