Perinatal Depression: The Most Common Complication of Childbirth

1
Perinatal Depression The Most Common
Complication of Childbirth  

• Katherine L. Wisner, M.D., M.S.
• Director, Womens Behavioral HealthCARE
• Professor of Psychiatry, Obstetrics and
  Reproductive Sciences, Epidemiology, Womens
  Studies
• Assoc. Investigator, Magee Womens Research Inst.
  
• Adjunct Faculty, RAND Corporation, Pittsburgh
• Western Psychiatric Inst. And Clinic/Univ.
  Pittsburgh
• www.womensbehavioralhealth.org www.MedEdPPD.org

2
Disclosures

• Pfizer Ziprasidone Pharmacokinetics during
  Pregnancy-closed by KLW
• GSK Speakers Bureau
• Donation of placebo patches from Novogyne
  Pharmaceuticals, a joint venture between Novartis
  Pharmaceuticals Corporation and Noven
  Pharmaceuticals, Inc., for an RCT of estradiol
  patch vs. sertraline vs placebo for PPD

3
Session 1
4
Perinatal Depression
5
Maternal Depression

• You say that Im depressed
• I wonder if you understand
• Youve never lived, I think
• In this God-forsaken land
• I always fight to function
• Im fighting to survive
• Im trying desperately to remember
• What its like to feel alive
• You say Im carrying life inside
• How can that really be?
• How could life possibly survive
• In a non-existent me?

6
Major Depression

• Over the last two weeks, most of the day nearly
  every day, five of the following (one symptom
  must be mood or interest)
• Depressed mood
• Diminished interest/pleasure
• Weight loss/gain unrelated to dieting
• Insomnia/hypersomnia
• Psychomotor agitation/retardation
• Fatigue or loss of energy
• Feelings of worthlessness/guilt
• Diminished ability to concentrate
• Recurrent thoughts of death

7
Postpartum Depression is NotThe Baby Blues

• Not a clinical disorder - 50 to 80 of new
  mothers, not usually seen by physicians
• Anxiety, mood lability, crying spells
• Transient, no pervasive mood disturbance
• Gone by day 10 postpartum!
• Differentiate from depression by transience and
  low-level symptoms be more suspicious if she has
  a history of depression

8
Postpartum Psychosis is not just really bad
depression

• Onset in first few weeks post-birth
  delusions/hallucinations are bizarre, cognitive
  difficulties prominent
• Bipolar disorder! Mania or psychotic depression
  use ECT, mood stabilizers
• Differentiate from obsessional thoughts
• Very high risk for recurrence after later births
  prevention for patients who have bipolar disorder
  is good management

9
Madness or Malice? Vermin or Victim?
10
Andrea Yates

• Devoted mother of five, nurse, home-schooling
  two suicide attempts in 1999
• She did not hide the crime. My children were
  not righteous. They were doomed to perish in the
  fires of Hell.
• She was Satan, he would be executed when she was
  executed, 666 on scalp
• Agreement severe mental disease, she knew
  killing was legally wrong, and she thought the
  killing was in the best interest of her children
  (altruistic homicide)
• Two weeks before the killings, her antipsychotic
  drug was discontinued

11
Epidemiology of Postpartum Episodes
12
Etiology Is it my hormones? (Bloch, Am J Psych
2000157924-930)

• Induced hypogonadism, added supraphysiologic
  doses of estradiol and progesterone for 8 weeks
  withdrew steroids double-blind model
• 5/8 women with history of PPD developed symptoms,
  0/8 women with no history
• Hormones interact with variable(s) to risk of
  depression but 25 of women who have had PPD
  develop it after subsequent births (not all!)
• Liability to depression stressful life events,
  genetic factors, prior history of major
  depression, neuroticism (Kendler, Am J Psych
  19931501139-1148

13
Depression and its Concomitants Affect Multiple
Domains of Perinatal Health

• Symptoms of Depressionphysiological
  dysregulation
• Appetite Effects
• Underweight, Overweight, Nutrition
• Cognitive changes attention to self and infant
  safety
• Prenatal/ postnatal care compliance
• Use of other drugs/smoking

14
Depression and its Concomitants Affect Multiple
Domains of Perinatal Health

• Choice of feeding methods for infant
• Psychosocial relationships are crucial for
  support after birth
• Marital discord
• Interactional partner for infant
• Use of health services for infant
• Loss of employment/ Health insurance

15
Treatment of Perinatal Depression
16
Treatment Principles

• Complex genetics-environmental interaction
  etiology creates multiple types of intervention
• Treat until well, not just better
• If a single episode, treat for six months after
  achieving wellness, longer for 2 episodes
  consider maintenance for 3 or more episodes
• Patient choice, treatment availability and
  resources are primary considerations

17
Clinical Stages in the Treatment of MDD
Time
Adapted from Kupfer DJ. J Clin Psychiatry.
199152(Suppl)28-34.
18
Pregnancy
19
Psychotherapy

• Spinelli MG Interpersonal Psychotherapy for
  depressed antepartum women a pilot study. Am J
  Psych 1541028-1030, 1997
• IPT, an effective form of treatment for
  depression, efficacy data for use during
  pregnancy
• Targets interpersonal distress and effect on mood

20
Interpersonal Psychotherapy

• 16-week RCT of IPT vs. parenting education
  control program (PEP)
• 50 enrolled 38 completers
• IPT gt PEP on Outcomes Edinburgh Postnatal
  Depression Scale (self-report), the Hamilton
  Depression Rating Scale, and Clinical Global
  Impressions
• IPT should be a first-line treatment in the
  hierarchy of treatment for antepartum depression
  

21
IPT-P vs. PEP in Depressed Pregnant Women EPDS
scores (p.005)
EPDS
IPT-P Phase
22
Supportive Psychotherapy
Freeman et al. Omega-3 fatty acids and supportive
psychotherapy for perinatal depression a
randomized placebo-controlled study. J Affective
Disord 110142-8, 2008
23
New Environmental Approaches

• Aerobic Exercise (gt 30 minutes of moderate
  intensity physical exercise, 3 to 5 days per
  week) Dunn et al, Am J Prev SRI 2005281-8, 2005
• Nutritional status Pregnancy and lactation as a
  nutritional challenge. Bodnar and Wisner. Biol
  Psych 58679-685, 2005.

24
Bright Morning Light Therapy

• Bright Morning Light Therapy, 10,000 lux
  commercial UV blocked box pregnancy-- Epperson
  et al. J Clin Psych 65421-425, 2004 Oren DA et
  al. Am J Psych 159666-669, 2002. Golden et al
  APA review and meta-analysis- Am J Psych
  162656-662, 2005
• Data support efficacy in non-seasonal depression
  a non-pharmacologic somatic RX for depression

25
Bright AM Light Treatment Pregnancy Oren et al.
Am J Psych 159666-669, 2002.
26
Toon
27
Risk-Benefit Decision-Making for Depression
during Pregnancy A Framework

• Wisner et al Risk-benefit decision-making for
  treatment of depression during pregnancy. Am J
  Psych 157 1933, 2000
• Healthy outcomes for mother and baby are the rule
  rather than the exception!

28
Depression Recurrence during Pregnancy

• Recurrence risk for women who either maintained
  or discontinued antidepressants proximal to
  conception (Cohen et al- JAMA. 2006295499-507)
• Significantly more women who discontinued
  (44/65, 68) compared to women who maintained
  (21/82, 26) antidepressant treatment suffered
  recurrent MDD.
• Most recurrences emerged rapidly (50 in the
  first trimester, and 90 by the end of second
  trimester).

29
Reproductive Outcome Domains Framework

• Intrauterine fetal death
• Major birth defects (approx 3 in the general
  population)
• Growth Effects
• Behavioral Teratogenicity
• Neonatal Syndrome
• Respiratory Distress Persistent
  Pulmonary
• Hypertension of the Newborn
• These domains are impacted by both psychiatric
  disorders and antidepressants

30
SSRI -Outcome Domains

• Intrauterine fetal death -No evidence
• Major birth defects Specific defects (if any)
  are rare and absolute risks are small. Greene,
  M. F. (2007). Teratogenicity of SSRIs -- Serious
  Concern or Much Ado about Little? NEJM 356
  2732-2733

31
Growth Effects SSRI use, gestational weight
gain and neonatal low birth weight

• Chambers et al. , NEJM 1996
• 100 exposed early 73 late (most through
  pregnancy)
• 3 X rate of preterm birth for FLX-exposed
• (14.3 late, 4.1 early, 5.9, control)
• For full term infants, birth weights, p.04
• 3589 500 g (early)
• 3392 500 g (late)
• 3556 50 g (control)
• Mean (SD) total maternal weight gain, p0.01
• Exposed early 37.4 (15.4) lb.
• Exposed late 30.8 (15.4) lb.

32
Analysis of gestational weight gain
Cumulative weight (g)
Weeks of gestation
Pregnancy costs 85,000 kcal Modified from
Hytten, 1991
33
Institute of Medicine weight gain recommendations
(1990)
Prepregnancy BMI (kg/m2) category Recommended total weight gain (assuming 40 wk gestation) Recommended rate of weight gain in 2nd and 3rd trimesters
Underweight (BMI lt19.8) 28 40 lb. 1.1 lb/week
Normal weight (BMI 19.8 26.0) 25 35 lb. 0.9 lb/week
Overweight (BMI 26.1 29.0) 15 25 lb. 0.66 lb/week
Obese (BMI gt29.0) 15 lb. lower limit Determined on an individual basis
for singleton gestations BMI, body mass index
(weight (kg) / height (m)2)
34
Antidepressant Use during Pregnancy (ADUP) Study
Five Exposure Groups (N238) Five Exposure Groups (N238)
No SRI, No MDD N131 No exposure to any antidepressant or MDD during pregnancy
Continuous SRI N48  Treatment with an SSRI during the entirety of pregnancy or for the majority of each of three trimesters
Continuous MDD No SRI N14  The presence of MDD throughout pregnancy or for the majority of each of the three trimesters with no antidepressant treatment
Partial SRI N23 Treatment with an SSRI at some point during pregnancy with at least one trimester without antidepressant exposure
Partial MDD No SRI N22 The presence of MDD at some point during pregnancy without MDD for at least one trimester without antidepressant treatment
35
ADUP Pre-Pregnancy BMI and Weight Gain
No SRI, No MDD SRI through MDD through-no SRI SRI partial MDD partial- no SRI p-values
Pre-preg BMI 26.0 27.0 30.5 26.0 29.3 .082
Weight Gain 32.3 28.6 17.7 31.4 24.8 0.17
within IOM 31.7 17.4 0 37.5 11.1
gtIOM 56.1 60.9 66.7 56.3 66.7 0.38
ltIOM 12.2 21.7 33.3 6.3 22.2
Weight Gain not signif. different across groups
pre-conception BMI higher in depressed women
36
ADUP Birth Weight
37
Preterm Birth and SSRI Depression or Drug
Treatment?

• Maternal SRI treatment associated with preterm
  birth across multiple studies
• Oberlander et al (Arch Gen Psych 63898-906,
  2006)
• studied SRI-exposed infants vs. DE exposed
• SRI gt DE on birth weight, gestational age,
  proportion born at lt37 weeks, neonatal
  respiratory distress, jaundice and feeding
  problems
• For propensity score matched DE exposed vs. SRI
  exposed neonates, ONLY BW below 10th percentile
  and respiratory distress remained
• Depression and SRI affect similar outcomes

38
Preterm Birth and SSRI Depression or Drug
Treatment?

• Prospective observational design, Suri et al
  (2007) studied 90 women
• 49 MDD treated with antidepressants during
  pregnancy
• 22 had MDD- not treated or limited exposure
• 19 had neither exposure
• Rates of preterm birth (14.3, 0, 5.3,
  respectively- again, 3 X greater for drug
  exposed
• Depression during pregnancy did not affect
  outcome measures
• SRI treatment was associated increased risk for
  preterm birth

39
ADUP Preterm Birth Rates
No Med, No MDD Med through MDD through-no Med Med partial MDD partial- no Med p-values
Gest Age 39.1 38.4 38.4 39.2 39.2 0.85

gt 37 94 77 79 96 91
34 to lt37 5 17 14 4 4.5 0.03
lt34 1 6 7 0 4.5
Preterm Birth Rates are higher in both SSRI
throughout and MDD throughout
40
Neonatal Syndrome

• Poor neonatal adaptation in 31.5 of infants in
  late-exposed group, 8.9 in early-exposure group
  for fluoxetine (Chambers et al, NEJM
  3351010-1015, 1996
• Acute effects or withdrawal possible from any
  antidepressant typically these are
  transient-about 2 weeks (Moses-Kolko et al, JAMA
  2932372-2382, 2005)
• Restlessness, rigidity, tremor
• Transient, usually less than two weeks
• No long term developmental sequelae

41
Specific Signs Reported to FDA AERS by Frequency
of Occurrence (N57 Infants)
? Yellow CNS Signs ? Red Neuro/muscular
signs ? Blue GI / Respiratory/ Autonomic signs
42
Do all SSRIs predispose to neonatal complications?

• Paroxetine
• Most common drug in the case literature
• High variability in onset time (birth5 days
  postpartum)
• Anticholinergic? cholinergic overdrive
• Fluoxetine
• 4-fold increase in relative to unexposed newborn
• Increased likelihood of respiratory disturbance
• Develops by 4 hours of life half-life (7 days)
• Sertraline, citalopram, escitalopram, fluvoxamine
• Make inferences based on pharmacology

43
Management Toxicity

• Taper maternal drug 10 days- 2 weeks prior to EDC
• if risk of maternal illness doesnt outweigh
  risk of complications
• Mild symptoms Conservative management
  strategies
• Frequent small feeds /high calorie if needed
• Five S of infant calming (Karp) Swaddling,
  Shhh, Soft Shaking, Sucking, Swinging
• Maternal skin to infant skin contact
• Severe symptoms
• What about drug management?

44
Persistent Pulmonary Hypertension of the Newborn

• Chambers et al (NEJM 354579-587, 2006) -
  increased risk of PPHN with SSRI treatment after
  20 weeks gestation.
• Odds of PPHN from late pregnancy compared to
  early or no exposure was 6.1 (95 CI2.2 -16.8).
• No increased risk of PPHN for nonserotonergic
  drug exposure
• No infant deaths is in this study
• Absolute risk 6 -12/ 1000 births (0.6 to 1.2)
• 14 SSRI exposed vs. 6 controls exposed.

45
From - http//www.health.uab.edu/14535/
46
ADUP Neonatal Syndrome

• Outcomes NICU admissions, 10 signs from PES,
  incl. respiratory signs
• NICU admissions not significantly different after
  adjustment for gestational age
• Neonatal signs did not differ across groups
  except for less favorable 5 minute Apgar scores
  in continuous SRI exposed compared to nonexposed
  infants.
• In our sample, there were low proportions of
  women exposed to high risk drugs -only 2 women
  were treated with paroxetine (5) and 10 with
  fluoxetine (25).

47
Take Home Points

• Intrauterine Fetal Death- No evidence women with
  SRI and/or depression exposure have a higher risk
  for miscarriage
• Physical Malformations- Specific defects (if any)
  are rare and absolute risks are small.
• Growth- Maternal Weight Gain, pregnancy duration,
  infant birth weight- No significant differences
  in weight gain due to SRI. SGA inconsistently
  reported.
• Preterm birth is a converging finding for SRI
  exposed neonates but however, depression is
  associated with the same level of risk for
  preterm birth.

48
Take Home Points

• Behavioral Teratogenicity- No differences in
  cognitive function, verbal comprehension,
  expressive language, mood, arousability, activity
  levels, distractibility, behavior problems,
  temperament (TCA, FLX) Casper et al (2003)
  reported less favorable motor (not mental)
  development in SSRI exposed vs. control in
  toddlers.
• Neonatal Syndrome- Time-limited lt 2 weeks, rarely
  requires medical intervention most commonly
  associated agents are paroxetinegtfluoxetinegtsertra
  linegt fluvoxamine citalopram escitalopram
• PPHN- Risk increased from 1-2/1000 to 6/12/1000
  with exposure to SSRI after 20 weeks gestation

49
FDA--Proposed Pregnancy and Lactation Labeling
Rule

• Remove ABCDX categories from ALL drugs
• Standard format and content requirements
• Merge pregnancy labor and delivery sections
• Lactation section-replace Nursing mothers
  section
• Require updating when new information available
• Pregnancy registry contact information
• Standard statement about background
  population risk of fetal abnormalities
• Three main parts
• Fetal risk summary
• Clinical considerations
• Data

50
Postpartum Depression
51
We can Treat Postpartum Depression Psychotherapy

• OHara (Arch Gen Psych 2000571039-1045)
• Interpersonal Psychotherapy, a manualized
  therapy, particular focus on role transition, 12
  weeks
• IPTgtWait list controls, who also responded when
  treated
• Measures of relationship with partners and
  overall function improved

52
Psychotherapy/Pharmacology

• The only placebo-controlled randomized clinical
  drug trial!
• Appleby (British Medical Journal 314932-936)
• Six sessions psychotherapy (cognitive behavioral
  counseling)gt 1 session
• Fluoxetine 20mg/daygtplacebo
• Six sessions and fluoxetine similar, not additive

53
Estrogen Treatment of PPD

• Beta-estradiol patch (200 mcg/d) vs placebo
• 63 women with PPD (onset within 3 months of
  birth) 35estradiol (18), placebo (17) 26
  estradiol (16), placebo (10) plus an
  antidepressant (augmentation)
• At one month, 50 of estradiol vs 26 of placebo
  group responded, sustained for 6 months (Gregoire
  et al, Lancet 1996347930-933) no replication
• We have NIMH funding to do an RCT of estradiol
  patch vs. sertraline vs. placebo
  www.womensbehavioralhealth.org

54
NIMH-funded StudyWisner KL, Hanusa BH, Perel
JM, Peindl KS, Piontek CM, Findling RL,
Moses-Kolko EL. Postpartum depression A
randomized trial of sertraline vs. nortriptyline.
J Clin Psychopharm 26 353-360, 2006.8 week
acute phase parallel design, 6 month
continuation phase,no placebo
55
NTP vs. SERT Randomized Controlled Trial, no
Placebo
Intake Acute Phase (Weeks) Acute Phase (Weeks) Acute Phase (Weeks) Acute Phase (Weeks) Acute Phase (Weeks) Acute Phase (Weeks) Acute Phase (Weeks) Acute Phase (Weeks) Continuation Phase (Weeks) Continuation Phase (Weeks)
1 2 3 4 5 6 7 8 12? 16 20? 24
S I1 A A A A P A P A P A P A
S Semistructured Screening Interview I1 Entry
interview Baseline measures A In-person
Assessment P Phone Interview
56
Intent to Treat Analyses - Primary Symptom
Outcomes at Weeks 4 and 8
Sertraline Sertraline Nortriptyline Nortriptyline
55 55 54 54
Week 4
Remitted 15 27 16 30
Responded 25 46 30 56
Week 8
Remitted 25 46 26 48
Responded 31 56 37 69
57
Doses of Subjects who Achieved Remission (wk 8)
in NTP vs SERT Trial
SERT, mg/day, N24 remitted
lt100 100 125 or 150 200
1 (4) 12 (50) 4 (17) 7 (29)
lt100 100 125 or 150
15 (58) 7 (27) 4 (15)
NTP, mg/day, N26, remitted
Start with 25 mg of sertraline or 25 mg of
nortriptyline half of usual starting dose of
any antidepressant
58
Nortriptyline vs. Sertraline

• Response and remission rates did not differ
• At 8 weeks, responders SERT56, NTP69
  remitters SERT46, NTP48
• Time to response and remission did not differ
• Psychosocial functioning improved similarly
• The total side effect burden of each drug similar
• No clinical (including O/C) or demographic
  variables IDd responders from nonresponders
• Medications similarly efficacious in women with
  non-postpartum depression

59
Breastfeeding and Antidepressants

• Data consist of mother and infant serum
  levels some test breastmilk
• The most data are available for sertraline,
  paroxetine, fluoxetine nortriptyline
• Usually below limit of quantifiability for
  sertraline, paroxetine, nortriptyline
• Adverse effects reported in breastfeeding infants
  whose mothers were treated with doxepin,
  fluoxetine, citalopram

60
Breastfeeding SertralineMaternal Dose Range
25-200 mg/day
61
Breastfeeding ParoxetineMaternal Dose Range
10-50 mg/day
62
Breastfeeding FluoxetineMaternal Dose Range
10-60 mg/day
63
Breastfeeding NortriptylineMaternal Dose Range
50-150 mg/day
64
Breastfeeding and Antidepressants

• Infants over 3 months of age are at low risk for
  adverse effects due to maturation of hepatic
  enzyme systems
• All published data are from full-term infants
  with one exception (35 week infant-NTP)
• Short term intense behavioral and long-term
  developmental studies are needed
• Infant serum level monitoring not recommended for
  healthy newborns (Weissman et al, 2004)

65
(No Transcript)
66
Mental Healthis Fundamental toHealth
David Satcher, M.D.
We must prioritize the mental health of the
mothers of our next generation!
67
Session 2

• Community Interventions

68
Our Public Health Challenge

• Lack of perinatal mental illness identification
  and treatment exists despite
• Effective therapies
• Easy to administer, reliable, valid and
  acceptable screening instruments
• Guidelines for the treatment of mood disorders
  during pregnancy
• Recommendations for screening
• AHRQ Report on Mental Health
• National Screening efforts
• Continuing media coverage of postpartum illnesses
  and their consequences

69
Public Policy for Perinatal Mental Health in the
US

• Several states (notably Illinois, New Jersey and
  Pennsylvania) have developed state-wide
  initiatives to improve mental health care for
  perinatal women
• These initiatives focus on screening practices,
  depression care management, and the development
  of accessible services for new mothers and
  families
• Policy development is becoming a national priority

70
US Governmental Action

• The Melanie Blocker Stokes MOTHERS Act (Moms
  Opportunity To Access Help, Education, Research,
  and Support for Postpartum Depression) passed
  overwhelmingly in House of Representatives, 10/
  2007
• Senate vote on July 28, 2008 to not consider The
  Advancing American Priorities Act at this time -
  included Melanie Blocker Stokes MOTHERS Act
• The Act is not dead ---reintroduced by Bobby
  Rush, D-Ill in January 2009
• Unprecedented coverage by major press agencies
  resulting in even more attention and awareness of
  the need for its critical initiatives for
  mothers, infants and families

71
Barriers to Translational Research
72
Is there a good screening tool?

• Edinburgh Postnatal Depression Scale (EPDS) Cox
  JL, et al. Br J Psychiatry 1987 150782-86
• 10 items self-report, feelings in previous 7 days
  
• Responses 0 (low risk) to 3 (high risk)
• Developed for postpartum period
• Easy to complete (lt 3 minutes)
• Validated in many populations
• Good sensitivity and specificity
• Available in 23 languages
• The PHQ-9, CES-D and Postpartum Depression
  Screening Scale are also used

73
NIMH funded Depression Screening Project

• Women given EPDS
• Home visit SCID diagnostic interview performed to
  evaluate women who score gt 10
• An RCT of telephone-based care management
  intervention for depression vs. usual care
  offered to all women who screen positive
  regardless of diagnosis (except active substance
  using, bipolar or psychotic).
• Longitudinal evaluation to 12 months with
  depression and maternal and child public health
  outcomes
• An add-on study for screening adolescents funded
  by Heinz Foundation

74
The Depression Care Managers Tasks

• Encourage patient self-management, attitudes,
  preferences and barriers to care
• Provide culturally appropriate education on
  depression and its treatment
• Encourage shared decision making between patient
  and provider(s)
• Identify the patients risk level
• Monitor symptoms and functioning

75
The Depression Care Managers Tasks

• Give feedback to the patient on her progress
  toward goals
• Encourage links to community resources
• For providers evidence-based protocols
• Support providers, facilitate communications
• Specialty consultation
• Referral facilitation/compliance
• Health Insurer Depression Care program/contact

76
Intake Sheets 7942
Eligible 7782 age lt18, or non-English speaking
Agreed to be called 5983 77 of eligible
At 4-6 weeks, pending 366
Not reached 4-6 weeks 1250
Reached 4367 73 of agreed
Screened 4286 98.4 of reached/ 56 of eligible
EPDS lt10 3701 86.4
EPDS gt10 585 13.6
Refused Home Visits 205 35 of EPDS positive
Pending Home Visits 22 4 of EPDS positive
Completed Home Visits 358 61 of EPDS positive
77
Diagnostic Distribution

• Primary Axis 1 SCID diagnoses were
• Major depression, 69
• Bipolar Disorder, 18
• Anxiety Disorder, 9
• Substance Use Disorder, 0.3
• Other, 2
• No diagnosis, 2

78
Onset Timing

• The onset of the identified episodes was
• during pregnancy, 27
• postpartum (within 4 weeks of birth), 37
• prior to pregnancy, 36

79
Comorbidities

• Early onset comorbidities were very common
• Women with anxiety disorders (with onset in
  childhood or adolescence) over half of the women
  
• Substance abuse/ dependencenearly 20
• Eating disorders close to 10

80
Discussion Points

• When to screen?
• Which screening tool?
• Will women accept screening? (56 of eligible
  completed)
• Will the women who screen positive accept further
  assessment via home visit? (61 of EPDS
  positive)
• Depression screen for MDD, for all Axis 1
  disorders, or a broader conceptualization?
• Diagnosis, or functional status?
• Effectiveness of Depression Care Management?
  (links to systems, systems enhancements)

81
Screening in Dubois, PA
Negative222 Positive89 58 accepted Treatment
82
Screening in Dubois, PA
Negative454 Positive112 74 Accepted
Treatment
83
Roadblocks to Treatment

• Fragmentation of medical services for women
  mentally ill mothers live between medical
  specialties
• Young women use few primary care services
• Attention to maternal mental illness is
  relatively recent in the Ob/Gyn community
• Pediatricians do not identify or treat maternal
  mental problems
• Stigma
• Fear of having baby removed from care

84
Depression as a Normal Response to a Difficult
Life

• You'd be depressed too if you lived my life
• Its like Hello! Walk in my shoes for one week,
  Youd be depressed too
• Depressed? Well yes, what else is new?

Carol Anderson, Ph.D.
85
Five Primary Factors that Contribute to
Non-Attendance

• Belief that only severe disorders require
  treatment
• Managing an ill child
• Poverty/abuse and other external stresses
• Fear of reprisals, blame (loss of child)
• Treatment perceived as irrelevant

Carol Anderson, Ph.D.
86
Strategies to Improve Engagement

• More time connecting with maternal views of
  problems and services
• Allow her to tell her story before intervening
• Creating frequent feedback loops i.e. Do I
  have that right? What did that mean to you?
  What would be helpful? Overt disavowal of blame
  
• Acknowledgement of reasonable nature of distrust
  of authority/system
• Re-focus clinicians expectations to womans goals
• Help for self will help child

Carol Anderson, Ph.D.
87
(No Transcript)
88
Dialectical BehaviorTherapy Skills Training
Healthy Start

• DBT developed by Marsha Linehan, Ph.D., for the
  difficult-to-treat patient
• Dialectics- two contradictory viewpoints that
  co-exist in the world

89
Behavior Therapy Backbone of DBT

• Principle You have to DO better before you FEEL
  better (not visa versa)
• Treats client as able of making changes if
  capable and motivated
• Dysfunctional behaviors are usually ineffective
  attempts to solve problems
• Behavioral analysis of behavior needing to
  change/causing problems
• Prioritization of problems by participant

90
Exploring the Problem

• Get SPECIFIC and DESCRIPTIVE about the problem
  behavior
• Go beyond global labels - Ex. STRESSED laying
  on couch all day, yelling at kids, etc.
• Find out patient goals and values
• Why is this a problem for her?
• What does she want to see different?
• Why did she ask for help?

91
Figure out what to do Solution Analysis
Strategies

• Identify goals, needs, and desires
• Generate solutions
• Evaluate solutions
• Choose a solution to implement
• Troubleshoot the solution
• Life is a process, full of experiments from
  which we learn and shape our behavior

92
Possible Approaches

1. Solve the problem
2. Change emotional reaction to the problem
3. Tolerate the problem
4. Stay miserable

93
Distress Tolerance Skills

• How do you get through an upsetting and difficult
  situation that cannot be fixed?
• Principle Learn to tolerate and accept losses
  and emotional pain as part of life
• Not intended to solve the problem just to get
  through a difficult situation without making it
  worse (Example Using drugs, quitting your job
  impulsively)
• Useful for impulsive behaviors

94
Distress ToleranceSelf-Soothethe Five Senses

• Vision
• Hearing
• Smell
• Taste
• Touch

95
Distress ToleranceIMPROVE the Moment

• Imagery
• Meaning
• Prayer
• Relaxation
• One Thing at a time
• Break
• Encouragement

96
What is Validation?

• Communicates Acceptance
• Finding wisdom/ accuracy in clients response
  Kernel of truth
• Therapist believes in clients ability to get out
  of misery and create a life worth living
• Validate participants pain and suffering
• Validate the difficulty of solving her problem(s)
• Validate their experience as it looks to the
  participant

97
Mindfulness

• Paying attention in a particular way on
  purpose, in the present moment, and
  nonjudgmentally
• 
  Kabat-Zinn,
  1994, p.4
• Mindfulness Key Concepts
• Awareness
• One thing in the moment
• Nonjudgmental
• Effectiveness

98
Emotion Regulation Skills

• Change by Acting Opposite to Painful Emotions
• When afraid, approach
• When depressed, get active
• When angry, gently avoid/ be kind
• Three hour webcast of DBT skill development for
  Perinatal Partnerships in Pennsylvania Link to
  the DBT webcast
•   http//familyplanning.org/dbt-training

99
Healthy Start Colocation Clinic

• State Funded Program
• Hybrid Team with HS and my team
• Located in community
• Partnership in intervention planning
• Recovery based

100
Infant Caretaking

• Attachment complex neuropsychiatric phenomenon
  that requires caregiver proximity, reciprocity,
  commitment to caretaking (physical needs, safety)

101
Interaction Styles of Depressed Mothers (Field,
2000)

• Withdrawn
• Minimal display of facial expression
• Difficulty showing emotion or talking with infant

• Intrusive
• Irritability
• Expressions of anger
• Demand reaction from the child

102
Infants Sensitive to Maternal Affect

• Infants learn through interactions with
  caregivers - contingent response
• All forms of communication (voice, face, touch)
  affected in depressed mothers
• Infants of depressed mothers
• Irritable and difficult to console
• Smile less and frown more
• More withdrawn and less responsive

103
Thats amazing! Tell me more!
104

• We can
• Show depression-like behavior with people who are
  not our moms!
• Have a difficult time regulating our emotions!
  (I cant self-soothe!)
• Get so upset that we make things more difficult
  for mom!

105
Infant Development

• Infant born with innate temperament
• Scaffolding by environment outside uterus from
  birth developmental trajectory enriched
  environments
• Interactional Quality- How does mother respond to
  the often dysregulated behavior of the newborn?

106
Infant Communication
107
Helping Mothers Applications of DBT Skills

• Self soothing, parallel infant soothing mother
  is the container for babys emotions
• Balance interpretation of babys emotions
• React with accepting affect
• Integrate with skills in DBT for distress
  tolerance, validation

108
Watching, Waiting, Wondering An exercise with
baby on Mindfulness

• WWW was modified from Muir E, Infant Mental
  Health Journal 319-328, 1992
• The infants inevitable dysregulated, uncontained
  states may provoke similar maternal states
  
• Infant receives mothers response (becomes
  cyclical)
• Play session, variable length based on babys
  age, mother comment on babys activities and her
  feelings about them

109
Watching, Waiting, Wondering An exercise with
baby on Mindfulness

• As the mom Watches, Waits and Wonders what does
  she see Star doing? What is Star thinking? How
  does what Star is doing affecting Mom?
• Putting mindfulness into the space, verbalizing
  the interactions which makes them available to
  active decision-making and application of skills
  

110
Mental Healthis Fundamental toHealth
David Satcher, M.D.
We must prioritize the mental health of the
mothers of our next generation!
111
Session 3

• Questions
• Treatment Explorations
• Discussion and Application

112
More Information- Pregnancy

• Developmental and Reproductive Toxicity
• www.toxnet.nlm.nih.gov (DART
  database-free)
• Organization of Teratology Information
  Specialists (OTIS) www.otispregnancy.org, (866)
  626-OTIS, or [phone]
• ACOG Practice bulletin Use of psychiatric
  medications during pregnancy and lactation.
  Obstetrics and Gynecology 1101179-1198
• Wisner KL et al Psychiatric Disorders, in
  Obstetrics Normal and Problem Pregnancies, 5th
  edition. Gabbe SG, Niebyl JR, Simpson JL, Galan
  H, Goetzl L, Jauniaux ERM, Landon M, Editors
  Elsevier, pages 1249-1288, 2007.

113
More Information Postpartum Depression

• Weissman et al, Pooled analysis of antidepressant
  levels in lactating mothers, breast milk, and
  nursing infants. Am J Psych 161(6)1066-78, 2004
• Moses-Kolko E et al. Neonatal signs after late in
  utero exposure to serontonin reputake inhibitors
  Literature review and implications for clinical
  applications. JAMA 20052932372-2383.
• Wisner KL et al. Postpartum depression A
  randomized trial of sertraline vs. nortriptyline.
  J Clin Psychopharm 26353-360, 2006.

114
More Information Postpartum Depression--
Websites

• NIMH-funded site (SBIR, Medispin, Inc)
  www.MedEdPPD.org (for physicians and patients,
  two entries)
• Postpartum Support International
• www.postpartum.net
• Center for Environmental Therapeutics,
  www.cet.org, for light therapy information
• Womens Behavioral HealthCARE, www.womensbehaviora
  lhealth.org

115
More Information Postpartum Depression

• Miller LJ. Postpartum Depression.
  JAMA 287762-765, 2002.
• Dr. Millers sites www.hfs.illinois.gov/mch
• www.psych.uic.edu/clinical/HRSA 1-800-573-6121
• Wisner KL et al.. Clinical Practice Postpartum
  depression. NEJM 347194-199, 2002.
• Wisner KL et al. A major public health problem
  Postpartum depression. JAMA 2962616-2618, 2006.
• Munk-Olsen T. New Parents and Mental Disorders A
  Population-Based Register Study.JAMA
  20062962582-2589

116
MedEd PPD www.MedEdPPD.org

• Profession Information
• Designed to provide professionals with the tools
  to successfully screen, diagnose, treat, refer,
  and engage women with PPD. These include
• Educational modules for CME/CE credit
• Interactive case studies
• Classic papers and current literature in the
  field
• Provider tools including diagnostic instruments
• Educational video presentations and discussions
• Comprehensive slide library with downloadable
  slides
• Events calendar
• Resources relevant associations, Web sites,
  books, journals, and other sources of further
  information

117
MedEd PPD www.MedEdPPD.org

• Mothers and Others
• The patient-oriented section of the site,
  contains such features as
• An easy-to-use online diagnostic test
• Information about the myths and realities of PPD
• Experiences of real women with PPD
• Answers to frequently asked questions from
  experts in the field and
• The Provider Search Directory that can help site
  visitors find a local healthcare professional
  trained in caring for women with PPD.

118
AHRQ Report

• Evidence Report/Technology Assessment
• Number 119 Perinatal Depression Prevalence,
  Screening Accuracy, and Screening Outcomes
• Prepared for
• Agency for Healthcare Research and Quality
• U.S. Department of Health and Human Services
• February 2005
• http//www.ahrq.gov/clinic/epcsums/peridepsum.htm

119
Guidelines

• ACOG Practice bulletin Use of psychiatric
  medications during pregnancy and lactation. ACOG
  Practice bulletin. Obstet Gynecol. 2008
  Apr111(4)1001-1020
• ACOG/APA guidelines for treatment of depression
  in pregnancy- collaborative project
• Wisner KL et al Psychiatric Disorders, in
  Obstetrics Normal and Problem Pregnancies, 5th
  edition. Gabbe SG, Niebyl JR, Simpson JL, Galan
  H, Goetzl L, Jauniaux ERM, Landon M, Editors
  Elsevier, pages 1249-1288, 2007.
• FDA Pregnancy and Lactation Labeling
  http//www.fda.gov/CDER/regulatory/pregnancylabeli
  ng/default.htm