start time: 2 minutes 38 seconds - new mexico state … using the edinburgh postnatal depression...
TRANSCRIPT
Peripartum Depression:
the Pediatric’s Perspective Why does it matter?
Presented by: Janelle Aragon, MD
Yolanda Ortega, RN
Kristi-An Walker, 20, from Angleton, Texas, called an
ambulance to her home in June and told them her child
was unresponsive even after she performed CPR
Lyndsey Walker, 20, with fiancé Andrew, experienced rare
postpartum psychosis following the birth of her daughter
Elizabeth, now 15 months old
Objectives Review Risk Factors associated with Peripartum Mood Disorders
List and describe 3 adverse outcomes for children of parents with Peripartum Mood Disorders
Be able to screen, assess for and recognize Peripartum Mood Disorders using the Edinburgh Postnatal Depression Scale
Evaluate Case Examples of peripartum depression and decide if there should be concern
Be able to answer: Why is this important to families in New Mexico?
Questions
Common Misconceptions Parents with postpartum depression look depressed,
are sad and cry all the time.
Only mothers get postpartum depression.
It only happens to those already depressed or with
mental health issues.
It occurs within the first few weeks postpartum and only
lasts a few weeks.
Common Misconceptions It will go away on its own.
If the pregnancy and birth go well, parents are not at
risk for postpartum depression.
If a patient has been diagnosed with postpartum
depression in a prior pregnancy, he/she will have it
again.
Feeling depressed and anxious are to be expected of
new parents.
Common Misconceptions Breastfeeding prevents postpartum depression
Nursing moms can’t take antidepressants.
Sleep will cure postpartum depression.
Women with postpartum depression will hurt their
children.
What parents are told: Just snap out of it
Pray harder
Stay busy
Focus on the positive
You’re just being selfish
I told you that you were too young to have a baby.
Why parents don’t seek help: They might think:
I’m suppose to be happy
This is suppose to be a joyful time
I made a mistake
I am not a good mother
My baby just doesn’t like me. He just keeps crying
Everyone was right. I am too young, I am a bad mom.
They wonder:
What will people think of me?
The big one: They will take my baby away!
“With a period prevalence of 21.9% the year after birth,
depression is a frequent complication of childbearing.
However, recognition and treatment rates are even
lower in pregnant and postpartum women (14%) than
in the general population (26%).” JAMA Psychiatry.
Published March 13, 2013.
Case of a Pregnant mom: A 16 year old girl reports to her school counselor that “a
friend” is pregnant with her first baby in her third
trimester of pregnancy and has not revealed to her
parents that she is pregnant. She is afraid of being
thrown out and is contemplating taking pills so it will “all
go away.” She is asking help on what to tell her friend
Concerning or not concerning?
New Mexico and Postpartum
Depression
According to the New Mexico Pregnancy Risk Assessment and
Monitoring System (PRAMS) Surveillance Report for birth years 2009-
2010:
Risk Factors History of depression
Depressive symptoms during pregnancy
Family history of depression
Premenstrual or oral contraceptive-associated mood
changes
Stress around child care
Psychosocial impairment in the areas of work,
relationships, and leisure activities.
Risk Factors Unwanted pregnancy with contemplation of termination
Poor relationship with own mother
Not breastfeeding or difficulties with breastfeeding
Young parents
Unemployment
Stressful life events in previous 12 months
Congenitally malformed infant, premature infant
Sick Child (hospitalized child)
Women with postpartum blues are at increased risk of developing postpartum depression.
New Mexico Pregnancy Risk Assessment and
Monitoring System (PRAMS) Surveillance Report
for birth years 2009-2010:
Peripartum Mood Disorders
Blues
Depression
Obsessive-Compulsive Disorder
Psychosis
Peripartum Anxiety/Panic Disorder
Postpartum Blues Transient Condition
Mild and rapid mood swings (i.e. elationsadness), irritability, anxiety, decreased concentration, insomnia, tearfulness, crying spells
40-80% of postpartum women experience this within 2-3 days after delivery
Peaks around the 5th postpartum day and resolves within two weeks
May represent prodrome of depression and symptoms should be monitored
Case of a postpartum mom: First time 15 year old mom status post C-section post-
op day 2 is with her mother when she starts crying and
tells her mother she feels empty. Mother calls the RN
worried about depression.
Concerning or not concerning?
Peripartum Mood Disorders Blues
Depression
Obsessive-Compulsive Disorder
Psychosis
Peripartum Anxiety/Panic Disorder
Peripartum Depression
Most recent onset of mood symptoms occurs during pregnancy or
in the 4 weeks following delivery
Duration: minimum of 2 weeks
Change in functioning
MUST have: depressed mood or
loss of interest/pleasure
Criteria for Peripartum Depression
Weight change
Insomnia: Inability to sleep when baby sleeps
Restless/slowed down
Low energy level/fatigue
Feelings of guilt: Feelings of inadequacy and of being a failure as
a mother
Can’t think or make a decision
Recurrent thoughts of death
Peripartum Depression
50% begin prior to delivery
Significant anxiety and panic attacks
Crying
Poor libido
Lack of interest in the baby
Overwhelmed or unable to care for baby
Not bonding with baby
Peripartum Depression
Thoughts
Intrusive
Suicidal
Scary: usually not revealed unless woman questioned directly
Obsessional thoughts about harming self or baby.
Recognized as illogical and intrusive not predictive of
suicide or infanticide.
Occasionally indicative of psychosis
Peripartum Mood Disorders
Blues
Depression
Obsessive-Compulsive Disorder
Psychosis
Postpartum Anxiety/Panic Disorder
Obsessive-compulsive disorder
Underappreciated
21% women have perinatal onset
Worsens in pregnancy and postpartum
60-80% co-morbidity with Major Depressive Disorder
Criteria Obsessions OR compulsions, Understands thoughts are
excessive or unreasonable, Causes distress, Intrusive thoughts, Seen
with depression, Intrusive, Violent thoughts of harm to child, Avoidant
behaviors to avoid harm, Often contamination fears, Usually not
associated with compulsions
Case of a postpartum mom: A 17 year old first time mom is postpartum 6 weeks. Prior
to delivery was in the Career Enrichment Program to
obtain her LPN. She frequently has thoughts about her
child being ill, and she believes that her child has all the
ailments of every sick child she has studied.
Concerning or not concerning?
Peripartum Mood Disorders
Blues
Depression
Obsessive-Compulsive Disorder
Psychosis
Postpartum Anxiety/Panic Disorder
Psychosis
This is not postpartum depression!
Rare (1-3 cases/1000 births)
May be more common in first time pregnancy
Abrupt onset
Amongst identified women: 4% risk of infanticide
Amongst identified women: 5% risk of suicide
Increased risk of psychosis
Prior postpartum mood episodes
Prior history of depression
Prior history of bipolar disorder (bipolar 1)
Family history of bipolar disorder
Risk of recurrence with each subsequent delivery is
30%-50%
Peripartum Mood Disorders
Blues
Depression
Obsessive-Compulsive Disorder
Psychosis
Peripartum Anxiety/Panic Disorder
Case
A 34 year old married, employed, elementary math
teacher requested urgent evaluation in the 10th week of a
wanted pregnancy. From the fourth week of gestation,
she had suffered from intractable vomiting and severe
anxiety with bouts of tearfulness she found frightening.
Concerning or not concerning?
Screening for Postpartum
Depression Screening is an on going process and should be
conducted by all providers who come in contact with
mothers and fathers and their young infants.
Research shows that most women feel comfortable
with the screening process.
If you don’t ask many parents will not tell. Using a
validated screening tool provides an opportunity to
explore the emotional adjustment new mothers and
fathers are experiencing.
Assessment Tools Beck Depression Inventory
Postpartum Depression Screening Scale
Center for Epidemiological Studies Depression Scale
PRIME-MD Patient Health Questionnaire
Edinburgh Postnatal Depression Scale
Edinburgh Postnatal Depression
Scale Can be used during pregnancy and postpartum
10 items, self-administered
Validated in 12 languages
Easy to score: Each response scored 0-3 with total of 30 possible
Score of 9-13 may indicate depression at-risk group
Score > 14 or greater is likely to be suffering from a depressive illness of varying severity and needs a careful assessment to confirm diagnosis
Does it work If a negative screen, <9, probability she did not have
depression was 99%.
If a positive screen, >14 probability of a major
depressive disorder was 57%
Providing some form of support to women who screen
positive appears to decrease depressive symptoms
Case of a postpartum mom: First time mom presents with her 5 day old baby for a
well baby check. Dad is concerned because mom
cries frequently. Mom assures the pediatrician that she
has always been a cry baby and is not depressed.
Concerning or not concerning?
What about Dad? 5% of dads overall from 1st trimester to 1 year after
delivery
26% occur/diagnosed at 3-6 months postpartum
Biggest correlation related to presence of depression in
the partner
Associated with significant relationship discord
Kim P, Swain JE. Sad dads: paternal postpartum depression.
Psychiatry (Edgmont) 2007 Feb;4(2):35–47.
Case of a postpartum dad: 16 year old male with his first child, starts saying and doing
things out of character per family: Becomes stoic with close
friends and family, irritable with everyone, doesn’t allow anyone
but himself or mother-of-baby to care for the baby.
Concerning or not concerning?
Treatment Support and reassurance to mom/dad and family
Adequate time for sleep and rest
Allow someone else to care for infant at night
Minor tranquilizers for insomnia
Medications
Counseling, Support groups
Light Therapy, ECT
Why does this go unrecognized? Discomforts in peripartum period (fatigue, difficulty
sleeping, low libido) similar to symptoms of depression and expected
Societal expectations of new mom
Reluctance to complain of mood
Only 1/3 of women with Postpartum depression believed themselves to have this disorder
80% women had not reported symptoms to health professional
Adverse Outcomes Inconsistent use of birth control unplanned
pregnancies
Parenting difficulties
Family and marriage difficulties
Personal suffering
Risk of child abuse
Suicide: Suicide accounts for about 20% of postpartum deaths and is the second most common cause of mortality in post-partum women.
Case of a postpartum mom: Mother of a 9 week old boy calls her girlfriend and tells her that
something is wrong. She has slept 5 hours total in 5 days. She
states she sees herself doing things to her child: while she is
cooking she sees herself put the baby in the oven, while she is
bathing the baby she sees herself pouring hot water on the baby
or letting the water cover the baby.
Concerning or not concerning?
Adverse Outcomes for the Family
Family Unit
Self-Neglect unintentional neglect of others
“Not present” compromise parental-child relationship
interferes with attachment and bonding
Relationship discord
Adverse Outcomes for Parenting
Parenting Capacity
Poor supervision of health and safety of the child
Poor judgment
“Absent” parent Unintentional neglect shame/guilt
withdrawal
Adverse Outcomes for the Child Duration of parental depression correlates with degree
of impairment for the child
Associated with developmental/cognitive, behavioral,
emotional problems in children
Adverse Outcomes for Child Peripartum depression poses a serious risk to Child
Development
Neuronal migration, pruning and synapse formation
Poor interaction: less engaged visually, lower activity levels
delay in fine and gross motor skills Poor social interaction
delayed language acquisition and social skills
Poor cognitive development
Cognitive and attention deficits
Adverse Outcomes for Child Behavioral
Secure attachments early in life are essential in the development of healthy social skills and behavioral patterns.
Interference with parental-infant bonding increases parent’s sense of shame and guilt neglect attachment disorder
Higher incidence of conduct disorders
Highest rate of preschool expulsion rates in the US
Inappropriate aggression
Emotional dysregulation
Adverse Outcomes for Child Social
Feeding is a social skill affected by absent parent
failure to thrive and consequences of malnourishment
Mom not eating maternal nutrition affects breastfeeding
and breast milk production premature cessation of
breastfeeding
Nursing infants gain less weight
Who detects postpartum depression?
Obstetrics/Gynecology, Nurse Midwifery:
14-30%
Problem: Women often not seen after 2-6 week
postpartum check
More than 75 % of women are undiagnosed and
untreated
Pediatricians How often do we see children accompanied by their
parents?
EVERY DAY!
Well Child visits occur:
Newborn, 2 week, 2-4-6-9-12 month visits AT LEAST
Sick Visits
Hospitalizations
Results of September 2013 0-8 9-12 >13 # tested
Mom 25 7 2 34
Dad 11 2 1 14
Total Score per
range
36 9 3 48
12/48 or 25% received more in depth conversation with medical
staff
All families received an informational packet
5 families accepted psychiatric consultation or Certified Nurse
Midwife consultation
This is where you come in!! You see these young parents more than medical
professionals do
You know them at their baseline
You have access to information we do not: school absences, behavioral changes, performance in class, observation with friends/family
Important stakeholders must be involved before the screening takes place. These stakeholders may consist of school administrators, teachers, families, and mental health organizations
How can you help? Be aware of this issue
Educate staff and families about Peripartum Mood Disorders
Screen young parents who are either expecting or have delivered (whether or not a child remains in the picture)
Identify support systems for these parents, including other family members willing to care for baby
Identify services in your area that can provide mental health services
How do we talk to parents?
How can we help? Observations and informal screening
Listen to c/o sleep problems and Ask More
Listen for signs of poor coping and Ask More
Note comments about infant and interactions with infant
Failure to thrive infants may be infants of depressed parents
Depressed parents may have difficulty focusing on infant’s needs
How can we help? Ask specifically about suicidal ideation. If the response
is positive or equivocal, then
Ask about specifics of ideation, plan or intent.
Assess risk factors for suicide
Develop a safety plan for further evaluation and treatment
Ask about anxiety symptoms
Ask about alcohol or other substance use
Resources https://womensmentalhealth.org
http://www.postpartum.net
Perinatal Clinic University of New Mexico Hospital
Anilla del Fabbro, MD Phone 505-272-6130
Case of a postpartum mom: Mother of a 9 week old boy. She starts to have loud thoughts in
her own voice. These thoughts tell her she is worthless, everyone
would be better off without her, and that she is a bad wife and
mother. While resting in an upstairs bedroom her thoughts wonder
what would happen if she just fell out the window. While walking
with her mother, her thoughts wonder what would happen if she
jumped in front of the car.
Concerning or not concerning?
Case continued: This mother was taken
immediately to be evaluated
at Psychiatric Emergency
Services.
She was admitted to the
psychiatric hospital where
she remained inpatient for 1
week while being started on
medication.
Summary Peripartum depression is a major problem in New
Mexico, which can have severe consequences on the
well-being of our children
We, as caregivers of children and young parents, have
an opportunity to identify, educate and provide services
for our families
References
Jane Knitzer, Suzanne Theberge & Kay Johnson. “Reducing Maternal Depression & Its Impact on Young Children”, National Center for Children in Poverty, Columbia University School of Public Health Jan 2008, http://www.nccp.org/publications/pub_791.html
Centers for Disease Control and Prevention. Prevalence of self-reported postpartum depressive symptoms--17 states, 2004-2005. MMWR Morb Mortal Wkly Rep. 2008 Apr 11;57(14):361-6.
Relation between perceived stress, social support, and coping strategies and maternal well-being: a review of the literature.Razurel C, Kaiser B, Sellenet C, Epiney M.Women Health. 2013;53(1):74-99. doi:
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Reliability of the postpartum depression screening scale in the neonatal intensive care unit.McCabe K, Blucker R, Gillaspy JA Jr, Cherry A, Mignogna M, Roddenberry A, McCaffree MA, Gillaspy SR.Nurs Res. 2012 Nov-Dec;61(6):441-5.
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References
Re: Maternal depressive symptomatology: 16-month follow-up of infant and maternal health-related quality of life.Stevens DG.J Am Board Fam Med. 2012 May-Jun;25(3):398.
Screening for depression and help-seeking in postpartum women during well-baby pediatric visits: an integrated review.Liberto TL.J Pediatr Health Care. 2012 Mar;26(2):109-17. doi: 10.1016/j.pedhc.2010.06.012. Epub 2010 Aug 11
Maternal psychopathology and infant development at 18 months: the impact of maternal personality disorder and depression.Conroy S, Pariante CM, Marks MN, Davies HA, Farrelly S, Schacht R, Moran P.J Am Acad Child Adolesc Psychiatry. 2012 Jan;51(1):51-61
Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries.Parsons CE, Young KS, Rochat TJ, Kringelbach ML, Stein A.Br Med Bull
Postpartum depression prevalence and impact on infant health, weight, and sleep in low-income and ethnic minority women and infants.Gress-Smith JL, Luecken LJ, Lemery-Chalfant K, Howe R.Matern Child Health J. 2012 May;16(4):887-93.
References
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