POSTPARTUM DEPRESSION

BEYOND THE BLUES

Debby Carapezza, R.N., M..S.N. Nurse Consultant, Reproductive Health Program Utah Department of Health

INCIDENCE 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

DEPRESSION IN WOMEN
Women are at increased risk of mood disorders during periods of hormonal fluctuation

premenstrual postpartum perimenopausal

THE RANGE OF POSTDELIVERY 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

POSTPARTUM 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

SYMPTOMS OF POSTPARTUM DEPRESSION

Hopelessness Helplessness Persistent sadness Irritability Low self-esteem Loss of pleasure in activities Mood changes Inability to adjust to role of motherhood Inability to concentrate Sleep /appetite disturbances

RANGE OF SYMPTOMS
Symptoms range

from mild dysphoria to suicidal ideation to psychotic depression

DURATION OF SYMPTOMS
Untreated, symptoms can last:

several months into the second year postpartum

THE 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

ETIOLOGY 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

POSTPARTUM DEPRESSION IN UTAH

What can PRAMS* data tell us?
*PRAMS is an ongoing, population-based risk factor surveillance system designed to identify & monitor selected maternal experiences that occur before & during pregnancy & experiences of the childs early infancy.

INDICDENCE 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

 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.

Higher rates of depression were noted among women who:

Had less than a high school education Were less than 19 years old Resided in a household with an income <$15,000 Experienced an unintended pregnancy Reported being abused before or during pregnancy Had 0 to 1 person as a source of social support Were not married Reported 6 to 18 stresses during pregnancy (sick family member, divorce, etc.)

THE IMPACT OF POSTPARTUM DEPRESSION

LONG 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

LONG TERM CONSEQUENCES OF PMD

Babies of mothers with PMD were perceived by their mothers as more difficult to care for and more bothersome.

POSTPARTUM 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

RISK FACTORS FOR PMD

-Family history of mood disorder -Client history of mood disorder prior to pregnancy -Anxiety/depression during pregnancy -Previous postpartum depression -Baby blues following current delivery -Child-care difficulties: feeding, sleeping, health -Marital conflict -Stressful life events -Poor social support

INTERVENTIONS
SCREENING FOR PMD

SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY:

Be unable to recognize she is depressed

SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY:

Believe her symptoms are normal for new moms

SCREEN 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

SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY:

Feel she is going crazy and fears her baby will be taken from her

WHEN 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

SCREENING 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

A 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

EDINBURGH 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

SAMPLE 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

SAMPLE 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

SAMPLE 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

TREATMENT
1. Educate the woman and her support system regarding the diagnosis of postpartum depression.

TREATMENT OPTIONS
Pharmacological intervention
Counseling, individual and/or group Support groups

PHARMACOLOGICAL INTERVENTION
Use of tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) may be indicated for both nonnursing 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

OTHER 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

Other 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

TREATMENT OF DEPRESSION PATIENT 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).

COUNSELING
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

Counseling - Cont.
Any woman with symptoms of psychosis or with serious suicidal/homicidal ideation should be referred for emergency psychiatric evaluation

SUPPORT GROUPS
Numerous postpartum support groups are available. Contact: Local mental health agencies Hospitals Websites

WEBSITE INFO & SUPPORT Depression After Delivery http://www.depressionafterdelivery.com Postpartum Support International http://www.postpartum.net/ The Postpartum Stress Center http://www.postpartumstress.com/ Postpartum Education for Parents http://www.sbpep.org Office on Womens Health http://www.4women.gov-pregnancy-after the baby is born-PPD

Websites 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)

SUMMARY
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

References
1. Beck AT, Ward, CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry. (June 1961). 4:6:561571. 2. Cox JL, Holden, JM, Sagovsky R. Edinburgh Postnatal Depression Scale (EPDS). British Journal of Psychiatry. (1987). 150:782-786. 3. Epperson CN. Postpartum major depression: detection & treatment. American Family Physician. (April 15, 1999). 59:8:2247-2254. 4. Mandl KD, Tronick EZ, Brennan TA, Alpert HR, Homer J. Infant health care use and maternal depression. Archives of Pediatric Adolescent Medicine. (1999). 153:(8):808-813. 5. Stowe Z. Depression after childbirth: I it the baby blues or something more? Pfizer Inc. January 1998. 6. Stowe ZN, Nemeroff CB. Women at risk for postpartum-onset major depression. American Journal of Obstetrics & Gynecology. (August 1995). 173:2:639-645. 7. Utah Department of Health. (2001). [Untitled]. Unpublished Maternal Mortality Review Program data.

References (cont.)
8. Utah Department of Health. (2001). [Untitled]. Unpublished PRAMS data. 9. Whiffen VE, Gotlib IH. Infants of postpartum depressed mothers: temperament and cognitive status. Journal of Abnormal Psychology. (1989). 98:3:274-279.