Perinatal Depression:

A Family Affair

New York State Nurse Practitioner

Association2015

Christine Kowaleski, MSN, NNP-BC, FNP, MHNP-BC

Crouse Spirit of Women

Objectives• List 3 risk factors for perinatal depression.• Identify 3 factors on how perinatal depression impacts

the family system.• State 3 resources available to families with perinatal

depression through postpartum support international.• Discuss the major change now required by Health Care

Providers in New York State with the new Maternal Depression Law

• State two paradigm shifts we will see over the next few years with HCP and maternal depression.

Do you need to hear this if you are not involved in obstetrical orpediatric care?

Wait…..answer after the presentation

1:4 Adults Suffer from Mental Illness in a given year

• Mood disorders such as depression are the third most common cause of hospitalization in the U.S. for both youth and adults ages 18 to 44.18

• Nami

Cindy Wachenheim, a lawyer and doting aunt who had dreamed of having a child, seemed fine after the birth of

her son, until he was about 4 months old.

Manhattan motherjumps eight stories to her death

Sources say Harlem lawyer Cynthia Wachenheim penned a 13-page,

handwritten suicide note before jumping out of an eighth-story window, taking her son, Keston, with her. The baby was saved from the impact

when the woman landed on her back on the pavement.

.

Cynthia Wachenheim, 44, who left a suicide notecastigating herself for being a bad mother, landed onher back after taking the fatal plunge

With her infant son strapped to her chest; baby survives with minor injuries

The mother accused of beheading her 3-month-old daughter may suffer from a condition called Postpartum Psychosis, a very rare but severe mental illness

Ohio

What a terrifying sight. A pregnant woman drove her minivan off the road, onto the beach, and directly into the ocean with her three small children in the back.

The incident happened on Tuesday, March 4, 2014 in Daytona, Florida.

Mother and Child Saved from Drowning in Atlantic CityATLANTIC CITY, NJ October 30, 2014

• Patricia Shurig, 24, is accused of throwing her six-week-old daughter into the water in Atlantic City, then jumping in herself.

• Family members say that Patricia Shurig has been very depressed since she gave birth over a month ago. The baby’s father reported that Patricia had been experiencing stress and perhaps had bipolar disorder. Bipolar disorder is one of the risk factors for postpartum psychosis, a rare and more severe perinatal mood disorder.

EmptinessIn her breathtaking new memoir,

Phenomenal: A Hesitant Adverturer’s Search for Wonder in the Natural World

Leigh Ann Henion 37, writes of the birth of her 5 year old son, Archer. “I love and marvel over him as if he were my own heart pushed into the world and still beating, set on top of my chest. Yet I cannot help but mourn the loss of something I can’t quite place, I have an inner emptiness-literal and figurative-that I have never felt before.”

Cops: Woman Tried To Kill Herself And Her Baby By Crashing Into House

• Southwest suburban woman was ordered held on $1 million bond Thursday after she tried to commit suicide by crashing her SUV, with her infant inside, Tuesday afternoon, police said. (Chicago)

PPD & PPMD:A growing problem no more head in the sand

• How will this impact your practice?

New Legislation

NYS Definition of Maternal HCP

• Physician, midwife, nurse practitioner, physician assistant, or other health care practitioner attending pregnant women or a woman up to one year after childbirth

• Including a practitioner attending the woman’s child up to one year after childbirth.

• Information on maternal depression• Current evidence base and professional guidelines for

maternal depression screening• Evidence-based tools for maternal depression screening.• Information about follow up support for patients, referral,

or treatment, community resources• Information will be posted on their website.

The New York State Commissioner of Health will make available to all providers:

Also……• Information on engaging support for the mother, which

may include communicating with the other parent of the child and other family members as appropriate and consistent with patient confidentiality.

Hospitals and Birth Centers• The commissioner will design a leaflet that will be

required to be distributed by every hospital and birth center at the time of pre-booking.

• This information will also be on the website. Hospital and providers are free to add to the information

• Information on PPD will be included in the top six languages spoken in the state.

Maternity Care Must:

• At minimum include parent education, assistance in breast or bottle feeding, education on maternal depression screenings and referrals, and the performance of any necessary maternal and newborn clinical assessments.

• Offer information about follow-up support for patients who require further evaluation, referral, or treatment including, when available, specific community resources.

Maternal Depression Screenings

• No insurer or corporation can limit a patient’s direct access to screening and referral for maternal depression.

• Mothers can choose who does the screening: OB/GYN or Pediatric service.

• Paradigm Shift #1

Options of Screening Tools:

• Edinburgh 10 questions • Edinburgh 3 questions• PHQ-2 (Patient Health Questionnaire) • PHQ-4 • PHQ-9

Then what do you do with the results?

Scores >10 of Concern; Never should the score over-ride clinical judgment

• A three-item anxiety sub-scale of the Edinburgh Postpartum Depression Scale turned out to be a better screening tool than the two other abbreviated versions which are almost the same as the commonly used Patient Health Questionnaire.

• For this sub-scale, new mothers were asked to answer "Yes, most of the time," "Yes, some of the time," "Not very often" or "No, never" to the following statements:

• (#3) I have blamed myself unnecessarily when things went wrong.• (#4) I have been anxious or worried for not very good reason.• (#5) I have felt scared or panicky for not very good reason.

• These questions were chosen because we are seeing that postpartum depression has a large anxiety component.

US New and World Report Health 2008

Baby Blues, PPD, Postpartum Psychosis

Baby Blues Postpartum Depression

Postpartum Psychosis

Incidence 80% 15-20% 0.1%-0.2%

Average Duration 4-14 days 2 weeks -12 months Variable: days to 4-6 weeks postpartum.

Symptoms Tearfulness, fatigueDepressed affect, Irritability

Depressed affect Feeling of Hopelessness, Poor Concentration, Decreased LibidoRecurrent thoughtsInsomnia/Hypersomnia

Delusions, Confusion, Sleep disturbances, unusual behavior, emotional liability.

Treatment Reassurance, emotional support.Observe, 20% will develop PPD in the first year

Psychiatric evaluation, Medication and Psychotherapy

Antipsychotics, antidepressants and possible in patient hospitalization

Why it is important that Mom gets an appropriate evaluation?

• People seek help when depressed or anxious, having panic attacks or when they can’t sleep or eat.

• People do not seek help when they are experiencing mania-unless S.O. notices that the grocery money is gone.

Depression is depression is depression…unless it’s more

Mothers with maternal depression are not different than other patients with major depressive disorder and they are very self focused.In treating MDD you must rule out Bipolar Mood Disorder

So how will your practice be different?• 1. It will be different because by coming to this talk

you will hear that 50% of the women who present with Postpartum Depression after delivery had symptoms during the antepartal phase of her pregnancy.

• 2. The longer a mother goes untreated the

higher the chance of long term morbidity to the

family and society

WHO GET’S PPD?• First of all we know that the number of women who have PPD is

higher than statistics published by virtue of this being a self reported mental illness

• Educated women feel shame that they have a mental illness and lower socioeconomic women fear losing their baby

• A previous history of depression/anxiety/mental illness• Baby in NICU• Birth Plans• Unsuccessful Breastfeeding• Other Stressors• Poor Coping Skills

Statistics• Baby Blues 80%• PPD 15-20%• PPP 0.1% of which there is a 5% suicide and 4%

infanticide rate associated.

• Depression was highest in the first year post partum (13.93 and 3.56 per 100 person-years among mothers and fathers, respectively).

• By 12 years of child age, 39% of mothers and 21% of fathers had experienced an episode of depression. A history of depression, lower parental age at the birth of the child, and higher social deprivation were associated with a higher incidence of parental depression. (CDC)

Suicide assessment:

• When and How?• Most common is an overdose• 1st month 10.5%• 3rd month 4 %• 12th month 10%

 • Suicide screening CSSRS Columbia Suicide

Rating Scale is free online 6 questions pertaining to the past month

• CDC approved; 103 languages Do not need to be a mental health professional to administer and interpret.

• MY3APP (coping APP)

PROFILE: Lower Socio-economic at highest risk…But don’t forget……….

Andrea Yates andCindy Wachenheim Andrea Yates RN

MD Anderson

Cindy Wachenheim 80% of my clients are Teachers?

Common ThemesWhat moms tell me• Birth Plan gone array• Lack of Sleep• Breastfeeding Issues• 1st Baby in thirties• Life altered• Lack of coping skills• Guilt• History of depression

What I see• Can’t plan birth or death• Insomnia vs mania• Guilt• Isn’t what she expected• Feelings of failure• Feeling alone• Guilt• Reluctance to medicate

Perinatal Depression is a Family Affair!!! Pardigm Shift#2Children who experience maternal depression early in

life may experience lasting effects on their brain

architecture and persistent disruption of their stress

response systems.(Harvard Center on the Developing Child)

How does Maternal Mental Illness affect the Child?

The Family Mobile

Working Papers at Center on the Developing Child (Harvard University)

• The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain

• Young Children Develop in an Environment of Relationships• Excessive Stress Disrupts the Architecture of the Developing Brain• Early Experiences Can Alter Gene Expression and Affect Long-Term

Development• Persistent Fear and Anxiety Can Affect Young Children’s Learning

and Development

• Maternal Depression Can Undermine the Development of Young Children

Exposure to maternal Depression in infancy causes stress hormone levels to become more extreme in adolescence

(Harvard University)

Mothers Without Depression Depressed Mothers0

10

20

30

40

50

60

70

80

DeprDeession feels

KEY: Depression feelsbigger than the person

Research-Children & Depressed Mothers

• Among the children of depressed mothers, 42% had at least one current psychiatric diagnosis, usually depression, anxiety, or behavioral problems—at the time when the mother came for treatment herself. The severity of the mother's depression predicted behavioral problems in the child. (Batten et. al 2012)

• Research shows that successful treatment of a depressed mother to remission is associated with reduction of symptoms in her children (Pilowsky et.al, 2014).

The longer a mother goes untreated the

higher the chance of long term morbidity to the family and society

Early Treatment Matters!

Journal of the American Academy of Child and Adolescent Psychiatry

• Israeli researchers studied three infant outcomes • social engagement• fear regulation, and • physiological stress reactivity

100 mother-infant pairs @ 9 months PP.

These three infant outcomes are considered foundations of social-emotional growth and are associated with the infant’s ability to manage physiological stress and regulate negative emotions.

Journal of the American Academy of Child and Adolescent Psychiatry• The researchers found that the babies of depressed mothers scored the poorest on all outcome

measures after 9 months.

• The infants showed the lowest levels of social engagement during interactions with their mothers, were unable to self-regulate during situations that introduced novelty, fussed and cried more often, and their physiological stress response showed both higher baseline levels and a more pronounced stress reactivity.

• Children of anxious mothers showed lower social engagement than children of control mothers but higher than children of depressed mothers. However, their physiological stress response was similar to children of depressed mothers.

• The mother’s sensitive behavior played an important role in shaping infant outcomes. Sensitive mothering was related to the infant’s social engagement and protected against the effects of maternal depression on the development of the child’s social skills.

• Maternal sensitivity also had a positive impact on the infant’s physiological stress response and reduced the degree of physiological reactivity as measured by cortisol reactivity to stress.

Postpartum depression prevalence and impact on infant health, weight, and sleep in low-income and ethnic minority women and infants.

• Study was aimed to investigate the prevalence of maternal depressive symptoms at 5 and 9 months postpartum in a low-income and predominantly Hispanic sample, and evaluate the impact on infant weight gain, physical health, and sleep at 9 months.

• Participants included 132 low-income mother-infant pairs who participated in a larger investigation on prenatal care utilization.

• Mothers were interviewed in person 24-48 hr. after birth and by phone at 5 and 9 months postpartum.

• Matern Child Health J. 2012 May;16(4):887-93. doi: 10.1007/s10995-011-0812-y.

Gress-Smith JL1, Luecken LJ, Lemery-Chalfant K, Howe R.

Postpartum depression prevalence and impact on infant health, weight, and sleep in low-income and ethnic minority women and infants.

• Clinically significant levels of depressive symptoms were reported in 33% of the women at 5 months postpartum, and 38% at 9 months postpartum.

• Higher depressive symptoms at 5 months were associated with less infant weight gain from 5 to 9 months, p = .002, increased infant physical health concerns, p = .05, and increased infant nighttime awakenings at 9 months, p = .001.

• Results suggest a striking prevalence of clinically significant depressive symptoms through 9 months postpartum in this very low income, largely ethnic minority sample. Further, the effects of postpartum depression include significant ramifications for infant physical health.

• Matern Child Health J. 2012 May;16(4):887-93. doi: 10.1007/s10995-011-0812-y.

Gress-Smith JL1, Luecken LJ, Lemery-Chalfant K, Howe R

Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women With Screen-Positive Depression Findings

• The study, which included a depression screening of 10,000 women who had recently delivered infants at single obstetrical hospital. (Largest study so far)

• In the study, 14 % of the women screened positive for depression. Of that group, 826 received full psychiatric assessments during at-home visits. Some of the key findings from those assessments:

• Wisner MD, 2013 JAMA

Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women With Screen-Positive Depression Findings

• In women who screened positive for depression, 19.3 percent thought of harming themselves.

• "Most of these women would not have been screened and therefore would not have been identified as seriously at risk," Wisner said. "We believe screening will save lives.”

• Suicide accounts for about 20 percent of postpartum deaths and is the second most common cause of mortality in postpartum women

• Wisner MD, 2013 JAMA

How Depression Affects The Family

• Moms who are depressed often suffer in silence -- but this common illness can also take a heavy toll on their children. That's why getting treated is more important than ever.

•• Missy Nicholson, of Grafton, Massachusetts, had

struggled with depression on and off since age 10, but it wasn't until she became a mother that she realized she wasn't the only one suffering because of her illness.

• Three years ago, when Nicholson was pregnant with her second child, she sank into a depression so severe that she spent most of each day in bed. "I didn't even get up to make my daughter breakfast or see her off to school," Nicholson recalls.

• Her daughter, Katherine, then 8, suddenly developed a phobia about going to school.

• Parents Magazine

The dangers of a Depressed Mom’s coping

What do you do?

• First, referral for services, while common practice, is not a highly effective strategy. Previous work shows that depressed mothers are often reluctant to accept services for themselves, and therefore, do not follow through with referrals to external services

Put the focus on the children

A key factor to consider when initiating pathways to prevention for children of depressed mothers is that the focus, for mothers, may need to initially be on their children.

Mothers overcome many barriers to seek services

for their children when they perceive their children

need help and may be willing to accept family-based

intervention approaches if providers focus their explanation

of these approaches on how they will benefit their children.

Services through PCP

• There is much less stigma involved for families when seeking services through primary care settings, as compared to specialty mental health settings, and therefore, these services are more likely to be utilized.

• Routine screening would help

Formal Child Care Can Buffer Effects of Maternal Depression

• Study authors conclude that modest amounts of formal child care in toddlerhood for the children of depressed mothers can have enduring benefits for the child.

• 438 mothers and children followed from pregnancy, women were classified as having no symptoms, intermittent symptoms or recurrent symptoms of depression when their children were toddlers.

• Women who had recurrent depression were significantly more likely to have children with behavioral problems at age 5 years.

• If the child spent about three hours a week in formal child care at age 2, the effect of maternal depression on child behavior was significantly reduced.  Informal child care did not have the same protective effect.

• American Academy of Pediatrics 06/13/2011

Consider the followingWhen mom is inpatient:

• Consider Choices• Sleep• Visitors• Nursery time

After Discharge:

• Keen assessments• Focus on the child• Discuss with S.O.• Decrease stigma-normalize as

much as possible.• Team with Crouse ---Share our

vision!

• Call me!!

Choices…..• All parents I have worked with have complained of lack

of sleep right from the delivery. Consider Nursery time?

Some Resources

• Psychological HealthCare Ron Fish 315-415-3455

• Christine Kowaleski PSI Co-ordinator– 315-546-5075

• CPEP@ St. JoesMYAPP3Postpartum Support International Postpartum Resource Center: Warmline

• Crouse Perinatal Family Support Group

Crouse Perinatal Family Support Group

• Wednesdays 6pm Marley Education Center• Parking and meeting is free

• Call 315-708-9748 to register

• This group includes pregnant and post partum mothers with depression, anxiety or difficulty adjusting parenthood. Families are welcome.

• Does not matter where the mother delivers!

IF A COMMUNITY VALUES ITS CHILDREN, IT MUST CHERISH THEIR PARENTS…………..JOHN BOWLBY

How can you help?TELL MOM:

SHE IS NOT ALONE

SHE WILL GET BETTER WITH HELP

IT’S NOT HER FAULT…

AND DON’T FORGET TO: JAM

JAM….JUST ASK MOM!!!!!

!

UNC's Postpartum Inpatient Care

The UNC Center for Women's Mood Disorders has opened a 5-bed unit for women with moderate to severe postpartum depression (PPD). Our unit is the first of its kind in the United States.(2014)

• UNC Center for Women’s Mood Disorders is directed by David Rubinow M.D., the Chair of the UNC Department of Psychiatry and an internationally known expert in the evaluation and treatment of women with mood disorders that occur during periods of hormonal change. Reproductive mood disorders include depression and anxiety disorders associated with the reproductive life cycle.

Brown Women’s and Infants• The Day Hospital• At the Women & Infants Day Hospital, we believe that pregnant and postpartum

women deserve specialized, comprehensive treatment in a comfortable setting. They deserve to receive treatment with medication from a healthcare provider with expertise in safely medicating pregnant and breastfeeding women. They deserve to be with other women suffering from psychiatric conditions at this time in their lives in order to help overcome the sense of shame and isolation that is particular to pregnant and post partum women with these conditions, in a setting that allows them to remain with their infants. This program is different from any other, and over 98% of our patients would recommend this or a similar program to others.

References:Chaudron, L.H.MD,MS,Szilagyl,MD,MPH,Campbell,JD,MBE,Mounts,K.O.MD,McInerny,T.K.MD.2007.Legal and ethical considerations:risks and benefits of postpartum depression screening at well-child visits. Pediatrics Vol.119No1 pp.123-128.

Conroy,S, Pariante, C M.D,. Marks,.Phil,D. Davies, H. Ph.D.,Farrelly,S.,Dip.,P.,Schacht,R.,Moran,P. M.D., (2011) Maternal Psychopathology and Infant Development at 18 Months: The Impact of Maternal Personality Disorder and Depression Kings College London, Institute of Psychiatry published online 24 November 2011.

Dave,S.,Petersen I.,Sherr,L.,NazarethI., (2010) Incidence of maternal and paternal depression in primary care: a cohort study using a primary care database.Arch Pediatr Adolesc Med. 2010 Nov;164(11):1038-44.

Dennis C-L, Ross LE, Grigoriadis S Published Online: 16 June 2010- See more at: http://summaries.cochrane.org/CD006309/PREG_psychosocial-and-psychological-interventions-for-treating-antenatal-depression#sthash.t1eSmOzg.dpuf

Kase, Lori Miller, Parents Magazine

Earls, Marion E. and the Committee on Psychosocial Aspects of Child and Family Health, Pediatrics 2010; 126:5 1032-1039

PilowskyD.,Wickramaratne,P., Poh,E.Hernandez,M.,Batten,L.,Flament, M.Stewart,J,Blies,Pierre,Weissman,M. 2014.Psychopathology and functioning among children of treated depressed fathers and mothers,Journal of Affective Disorders.Aug.2014.V164.Pg.107-111

Rishel,C. (2012) Pathways to prevention for children of depressed mothers: A review of the literature and recommendations for practice.Depress Res Treat. 2012; 2012: 313689.Published online Jan 31, 2012.

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