Title: POSTPARTUM DEPRESSION BEYOND THE BLUES
1POSTPARTUM DEPRESSION BEYOND THE BLUES
- Debby Carapezza, R.N., M..S.N.
- Nurse Consultant, Reproductive Health Program
- Utah Department of Health
2INCIDENCE 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
3DEPRESSION IN WOMEN
- Women are at increased risk of mood disorders
during periods of hormonal fluctuation- - premenstrual
- postpartum
- perimenopausal
4THE RANGE OF POST-DELIVERY 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
5POSTPARTUM 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
6SYMPTOMS OF POSTPARTUM DEPRESSION
7RANGE OF SYMPTOMS
- Symptoms range-
- from mild dysphoria
- to suicidal ideation
- to psychotic depression
8DURATION OF SYMPTOMS
- Untreated, symptoms can last
- several months
- into the second year postpartum
9THE ETIOLOGY OF POSTPARTUM DEPRESSION
- Various theories based in physiological changes
have been postulated - hormonal excesses or deficiencies of estrogen,
progesterone, prolactin, thyroxine, tryptophan,
among others
10ETIOLOGY OF POSTPARTUM DEPRESSION
- Other theories cite numerous psychosocial factors
associated with PMD - 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
11POSTPARTUM DEPRESSION IN UTAH
- What can PRAMS data tell us?
12INDICDENCE 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
13- 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.
14Higher rates of depression were noted among women
who
15THE IMPACT OF POSTPARTUM DEPRESSION
16LONG TERM CONSEQUENCES OF PMD
- Negative impact on the infant s social,
emotional and cognitive development - 2 month old infants of mothers with PMD had
decreased cognitive ability and expressed more
negative emotions during testing
17LONG TERM CONSEQUENCES OF PMD
- Babies of mothers with PMD were perceived by
their mothers as more difficult to care for and
more bothersome.
18POSTPARTUM 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
19RISK FACTORS FOR PMD
20INTERVENTIONS
21SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY
- Be unable to recognize she is depressed
22SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY
- Believe her symptoms are normal for new moms
23SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY
- Fear being labeled a bad mother if she admits
her maternal experience does not meet societys
picture of bliss
24SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY
- Feel she is going crazy and fears her baby will
be taken from her
25WHEN TO SCREEN FOR PMD
- At preconception visit
- During prenatal intake subsequent visits
- During postpartum exams
- During infants 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 mothers visits for routine episodic care
26SCREENING TOOLS
- There are several tools available
- 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
27A 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
28EDINBURGH 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
29SAMPLE EPDS QUESTIONS
- 1. I have been able to laugh see the funny
side of things - As much as I always could
- Not quite so much now
- Definitely not so much not
- Not at all
30SAMPLE EPDS QUESITONS (Cont.)
- 3. I have blamed myself unnecessarily when
things went wrong - Yes, most of the time
- Yes, some of the time
- Not very often
- No never
31SAMPLE EPDS QUESTIONS (Cont.)
- 6. Things have been getting on top of me
- Yes, most of the time I havent been able to cope
at all - Yes, sometimes I havent 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
32TREATMENT
- 1. Educate the woman and her support system
regarding the diagnosis of postpartum
depression.
33TREATMENT OPTIONS
- Pharmacological intervention
- Counseling, individual and/or group
- Support groups
34PHARMACOLOGICAL INTERVENTION
- Use of tricyclic antidepressants and selective
serotonin reuptake inhibitors (SSRIs) may be
indicated for both non-nursing 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
35OTHER 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 - unknown impact of long-term use of medications on
neurodevelopment of infant
36Other 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 clients chart
37TREATMENT OF DEPRESSIONPATIENT 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 20mg qd X 30 Days 85.39
- Prozac 20mg qd X 30 Days 67.79 (generic)
- Zoloft 50mg qd X 30 days 75.00
- Elavil, at approximately 75mg qd X 30 days
11.39 (generic) or 37.89 (brand).
38COUNSELING
- Know referral sources in your locale, especially
those that - 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
39Counseling - Cont.
- Any woman with symptoms of psychosis or with
serious suicidal/homicidal ideation should be
referred for emergency psychiatric evaluation
40SUPPORT GROUPS
- Numerous postpartum support groups are available.
Contact - Local mental health agencies
- Hospitals
- Websites
41WEBSITE INFO SUPPORT
- Depression After Delivery - http//www.depressiona
fterdelivery.com - Postpartum Support International
-http//www.postpartum.net/ - The Postpartum Stress Center -http//www.postpartu
mstress.com/ - Postpartum Education for Parents
-http//www.sbpep.org - Office on Womens Health -http//www.4women.gov-pr
egnancy-after the baby is born-PPD
42Websites and Other Resources
- Mental Health Association in Utah
- http//www.xmission.com/mhaut/
- For information on medication while
breastfeeding, call Pregnancy RiskLine - In Salt Lake City 328-BABY (2229)
- Outside Salt Lake 1-800-822-BABY (2229)
43SUMMARY
- Postpartum depression
- is relatively common
- may have long-term consequences for mother,
infant family - is easily missed
- should be screened for
- can be treated successfully