Postpartum Depression

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Postpartum Depression
Postpartum Depression

• Lucy J. Puryear, M.D.
• Private Practice Houston, Texas
• Clinical Assistant Professor of Psychiatry
• Baylor College of Medicine

Lucy J. Puryear, M.D. Private Practice Clinical
Assistant Professor of Psychiatry Baylor College
of Medicine
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Depression in Women

• Occurs twice as often in women as in men
• Lifetime prevalence of 21.3 compared to 12.7 in
  men
• Factors may include
• psychosocial events
• brain structure and function
• hormonal factors

(Kessler et al, 1993)
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Age at First Onset of Major Depression
U.S. ECA
Females Males
4.0
3.5
3.0
2.5
Rate Per 100
2.0
1.5
1.0
0.5
0.0
0-14
15-24
25-34
35-44
45-54
55-64
Age at First Onset (Years)
Weissman et al. JAMA. 1996276-293 (Epidemiologic
Catchment Area Study, N18,000)
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Hypothalamic-Pituitary-Ovarian Axis
NE DA
5-HT
Hypothalamus
GNRH
(-)
Pituitary
(-)
(-)
LH FSH
Progesterone
Estrogen
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Estrogen and Serotonin

• Increases the rate of degradation of MAO1
• Displaces tryptophan from plasma albumin binding
  sites2
• Increase in the density of 5-HT2A binding sites
  in the CNS3
• Increase in tritiated imipramine binding sites4
• Increase in serotonin transport

1Luine, 1977 2Aylward, 1973 3Fink, 1996
4Sherwin, 1990
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Psychiatric Hospitalizations forWomen During
Postpartum Years
60
All Admissions Admissions Per Month
50
40
30
20
10
1 Year
-1 Year
-2 Years
Childbirth
2Years
Psychosis Admissions Admissions Per Month
50
40
30
20
10
1 Year
-1 Year
2Years
-2 Years
Childbirth

• Kendell RE et al. Br J Psychiatry.
  1987150662-673

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Baby Blues

• Occurs in 80 of deliveries
• Symptom onset day 3 postpartum
• Remits by 2 weeks
• Tearfulness, mood lability
• Likely to be response to rapid change in hormone
  levels

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Postpartum Depression

• Occurs in every one out of ten women postpartum
• Greater than 60 have symptom onset within 6
  weeks
• DSM IV requires symptom onset within 4 weeks
• May not present until several months after
  delivery when symptoms are severe

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Risk factors

• Previous episode of depression
• Severe PMS
• Depression during pregnancy, particularly third
  trimester
• Prior episode of PPD 50-70 risk of recurrence
• Family history of depression
• Family history of bipolar disorder
• Poor marital support

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Postpartum Depression

• Pregnant women have the same risk of depression
  as other non-pregnant women
• During the first month postpartum, childbearing
  women have a 3x greater risk for depression
  compared to nonchildbearing women

Cox JL et al. Br J Psychiatry. 199316327-31
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Key Signs and Symptoms

• SLEEP DISTURBANCE may be hallmark of illness
• Ruminations about infant
• Mood swings
• Loss of appetite
• Anxiety out of proportion to event
• GUILT

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Are you able to sleep when the baby is sleeping?
Are you able to sleep when the baby is
sleeping?
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Risk factors

• Previous episode of depression
• Severe PMS
• Depression during pregnancy, particularly third
  trimester
• Prior episode of PPD 50-70 risk of recurrence
• Family history of depression
• Family history of bipolar disorder
• Poor marital support

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Treatment
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Acute Interventions

• Mother MUST get uninterrupted sleep
• Recruit ANYONE to help mother, in-laws,
  neighbors, sisters, church members
• If breastfeeding allow someone else to feed
  infant at night with expressed breast milk or
  formula
• Consider discontinuing breastfeeding

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Non-Pharmacologic Interventions

• Support groups
• Interpersonal Psychotherapy dealing with loss
  and role change
• Light therapy

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Pharmacologic Treatment
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Tricyclic Antidepressants

• No adverse reports in infants
• Respiratory distress in one infant exposed to
  doxepin (Sinequan)
• Minimal levels of parent compound and metabolite
  found in infant serum
• Nortriptyline has a therapeutic window

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Sertraline and Breastfeeding

• Sertraline and desmethysertraline present in
  breast milk, below the detection of most
  commercial laboratories
• Highest concentrations found in hind milk 8
  hours after maternal dose.
• Increasing dose increased breast milk
  concentration
• No adverse effects on infant noted

(Stowe et al, 1997)
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Paroxetine and Breastfeeding

• Breast milk and mother and infant sera collected
  in 16 mother/infant pairs
• Paroxetine doses of 10-50 mg/day
• Present in all breast milk samples
• Greatest in hind milk
• No detectable concentrations of paroxetine found
  in infant sera

Stowe et al. Am J Psychiatry, 2000
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Weight Gain in Fluoxetine Breastfed Infants

• Retrospective cohort study
• 64 women took fluoxetine during pregnancy
• 26 of these women breastfed on fluoxetine
• 38 breastfed off of medication
• Infants exposed during breastfeeding had a
  statistically significant deficit in weight (avg.
  392 g)
• No abnormal behavior noted

(Chambers et al. Pediatrics 1999)
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Third Trimester Prophylaxis
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Neonatal SSRI Withdrawal?

• Studies not well controlled for maternal
  depression
• Unclear whether SSRI alone or combined
  pharmacotherapy
• Recommendations do not take into account maternal
  need for psychiatric medication

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Fluoxetine and Neurodevelopment

• 80 children TCA exposure, 55 Fluoxetine, 84
  controls
• Children age range of 16 to 86 months
• No difference in IQ scores or language
  development
• No differences noted between first trimester
  exposure only Vs. entire pregnancy

(NEJM, 1997)
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Third Trimester Exposure to Paroxetine

• Comparing 27 women with 1st and 2nd trimester
  exposure to paroxetine and 27 with
  non-teratogenic exposure to 55 women with 3rd
  trimester exposure
• 12 with complications 9 respiratory distress, 2
  hypoglycemia, 1 jaundice
• Compared to 3 in comparison group

Arch Pediatr Adolesc Med, Nov 2002
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Symptoms of Neonatal Withdrawal?

• Mild respiratory distress
• Hypotonia
• Tremulousness
• Excessive crying
• Diminished pain response
• Hypertonia

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Neonatal Complications

• 17 infants with neonatal complications
• Admission to special care nursery brief
• n11
• All but two infants went home with mother
• TTN, infant jittery, infant pale, lethargy,
  meconium, grunting

(Cohen et al., Biol Psychiatry 2000)
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ConsiderEffects of Untreated Maternal Depression

• Negative and disengaged parenting behaviors
• Children more likely to experience psychiatric
  illness
• Greater risk of insecure infant attachment
• Higher serum cortisol levels in child correlating
  with severity of maternal depression

• EEG changes in frontal lobe correlating with
  behavioral problems
• Untreated maternal depression during pregnancy
  higher cortisol levels at 6 mos. of age
• Alterations in Hypothalamic-Pituitary-Adrenal Axis

Newport et al. Am J Psychiatry 2002
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Impact of Maternal Depression

• Cohort of 160 infants of depressed mothers and
  160 infants of healthy mothers
• Infants and mothers assessed at 2, 6, and 12
  months
• Infants of depressed mothers showed significant
  growth retardation at all time intervals
• RR for 5 or more diarheal episodes 2.4 (1.7-3.3)

Rahman A, et al, Arch Gen Psych, 2004
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Postpartum OCD and Anxiety

• Extremely common and often comorbid with
  depression
• Intrusive thoughts or images of harming baby or
  something harmful happening
• Terribly distressing and incapacitating
• Will not volunteer this information, must
  directly ask
• Afraid to be alone with the baby

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Treatment

• Antidepressants must be given at OCD dose
• Fluoxetine 40 to 80 mg
• Sertraline 150 to 200 mg
• Paroxetine 40 to 60 mg

• Cognitive-behavioral therapy
• Support groups
• Social support

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Postpartum Psychosis A Psychiatric Emergency
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Postpartum Psychosis

• Occurs in 0.1 of deliveries
• 50 of women will later be diagnosed with bipolar
  disorder
• Recurrence rate extremely high with more severe
  episodes common
• Onset fairly rapid, within 3 days to one week

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Postpartum Psychosis

• Typical symptoms revolve around the infant.
• Aggitation and anxiety, disorganized behavior.
• Delusion about the infant.
• Altruistic infanticide.

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Prevention

• Prophylactic antidepressants
• Omega-3 fatty acids (fish oil)
• Interpersonal psychotherapy
• Close psychiatric follow-up during subsequent
  pregnancies

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Practice Management

• Identify women at risk
• Psychiatric referral prior to delivery
• Follow-up by phone two weeks after delivery
• Postpartum depression brochure in take home
  packet with numbers to call
• Consider Edinburgh scale at six week visit

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Yates Children Memorial Fund of the Mental Health
Association of Houston

• Focus on education, research, referrals, and fund
  raising
• Hope to have postpartum depression handout in the
  hands of every woman delivering a baby in the
  greater Houston area

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HOUSE BILL 341

• September 1, 2003

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House Bill 341

• A hospital, birthing center, physician, nurse
  midwife, or midwife who
• Provides gestational care or care at delivery
  must
• Provide a resource list
• Doccument in patients record
• Retain doccumentation for three years

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Summary

• Postpartum illness is under recognized and under
  treated
• Not treating causes harm to both mother and her
  baby
• Every woman after delivery should be screened for
  symptoms of postpartum psychiatric disorders

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