Screening for

perinatal

depression

ACOG CO No. 757, Nov 2018

Kristen Giefer, PGY-2

Introduction

– Prevalence of perinatal depression is a significant cost to individuals, children, families and the community

– In 2011, 9% of pregnant women and 10% of postpartum women met criteria for major depressive disorders

– Important to identify pregnant and postpartum women with depression as perinatal depression and other mood disorders can have devastating effects

– Regular contact with the healthcare delivery system during perinatal period should provide an ideal circumstance for women with depression to be identified and treated

– ACOG recommends that OBGYNs and other obstetric care providers screen at least once during the perinatal period with a standardized and validated tool

– ACOG recommends completing a full assessment of mood and emotional well-being during the postpartum visit with a validated instrument

– When indicated, OBGYNs and other obstetric care providers share a role in initiating medical therapy and/or referring to appropriate behavioral health resources

DepressionMost common mood disorder in

the general population

Approximately twice as common

in woman than in men

Initial onset peaks in

reproductive years

Major depressive disorder: Requires 5 or more sx- One major, anhedonia or dysphoria- Four or more minor symptoms- Must be present for two consecutive weeks

Minor depression: Requires 2-4 sx- One major, anhedonia or dysphoria- Must be present for at least two consecutive

weeks, but < two years

Perinatal Depression

– Perinatal depression includes major and minor depressive episodes that occur during pregnancy or in 12 months after delivery

– One of the most common medical complications during pregnancy and postpartum period affecting 1 in 7 women

– Perinatal depression and other mood disorders, such as bipolar and anxiety disorders, can have devastating effects on women, infants, and families

– Maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality

– Often goes unrecognized as changes in sleep, appetite, and libido may be mistaken for normal pregnancy and postpartum changes

– Women may be reluctant to report changes in their mood

– Obstetric providers should collaborate with pediatric colleagues to facilitate treatment for women with mood disorders identified during newborn care

Risk factors

– #1 risk factor for postpartum depression is past hx of perinatalor nonperinatal depression

– Prospective study of pregnant women (n > 1000) showed risk of perinatal major or minor depression was > double in women with history of depression compared with women without history of depression

– Prospective study of postpartum women (n > 200) found that postnatal major depression was 5x more likely in women who were depressed during their pregnancy, compared to those who were not depressed during their pregnancy

– Retrospective study of women with postpartum depression (n = 459) found > 50% were depressed during their pregnancy

Perinatal mood disordersAnxiety disorders, major depressive disorders, bipolar disorder, postpartum psychosis

– Bipolar disorder – major depression characterized by mania or hypomania

– Nationally representative survey of US general population estimated that among postpartum women, 12 month prevalence is 2.9%

– Risk of acute episodes in bipolar females is greater in the puerperium (52% in postpartum period vs. 23% in antepartum)

– Meta-analysis of 25 prospective and retrospective observational studies of 35,000 bipolar women and > 5,000 deliveries, acute mood episode occurs after approximately 37% of deliveries

– Risk factors: lack of maintenance of pharmacotherapy, prenatal mood symptoms/episodes, young age, unplanned pregnancy, primiparity, hx of postpartum mood disorder, family history of mood disorder or postpartum psychosis

– Increased risk of psychosis (delusions and hallucinations)

– Comorbid anxiety and substance use disorders are common among postpartum bipolar depression

– Concern for mania or bipolar disorder warrants referral to psychiatrist before initiating medical therapy because antidepressant monotherapy may trigger mania psychosis

Bipolar disorder– Characterized by episodes of major depression, mania, and hypomania

– Mania – distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally or persistently increased activity or energy, lasting at least one week and present most of the day nearly everyday + 3 or more of the following:

– inflated self-esteem or grandiosity, decreased need for sleep, pressure to keep talking, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal directed activity or psychomotor agitation, excessive involvement inactivities that have high potential for painful consequences

– Mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features

– Hypomania - distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally or persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day nearly everyday + 3 of sx listed above

– Episode is associated with unequivocal change in functioning that is uncharacteristic of individual when not symptomatic

– Disturbance in mood and change in functioning is observed by others

– Episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization

– If there are psychotic features, the episode is considered manic

Perinatal mood disordersAnxiety disorders, major depressive disorders, bipolar disorder, postpartum psychosis

– Postpartum psychosis – bipolar patients are at increased risk for postpartum psychosis (presence of delusions and hallucinations)

– Estimated rate of puerperal psychosis in general population is 1 to 2 per 1,000 live births; rate may be as high as 260 per 1000 deliveries in bipolar women

– Risk factors for psychosis include delivery complications (breech, fetal distress, cord accidents), prenatal mood disorders, prenatal obstetric complications (hyperemesis, preeclampsia, premature contractions)

– 2 retrospective studies of patients admitted for postpartum psychosis (n = 9 and 50) found that the underlying diagnosis was bipolar disorder in 31% and 32%, respectively

– Many patients who present with postpartum psychosis are ultimately diagnosed with bipolar disorder

– Anxiety and insomnia are prominent features of mood disorders and women should be asked about intrusive or frightening thoughts, or if they are unable to sleep even when their infant in sleeping

Pathogenesis

– Unknown

– Is it a distinct reproductive subtype?

– What degree of underpinnings of postpartum depression differ from those of nonperinatal depression?

– Genetic susceptibility – study postpartum women (n =328) found if one sibling had an episode of major postpartum depression, risk of an episode in other sibling was increased by fourfold

– Hormonal changes – changes in serum concentrations of estrogen, progesterone, cortisol, melatonin, oxytocin, and thyroid hormone have been associated with postpartum depression

– One study designed to mimic hormonal changes occurring at parturition compared 8 women with a history of major depression and 8 women without

– Treated women with supraphysiologic doses of estrogen and progesterone and then withdrew hormones over the following 4 weeks

– Increased depressive symptoms occurred in 5/8 of women with history of depression but in none of women without a history of depression concluding that those with a history were unusually sensitive to abrupt decreases in gonadal steroids

– Increased sensitivity to normal changes may predispose some women to depression

Adverse consequences

– Impaired breastfeeding - Prospective study (n > 5000) found breastfeeding was observed in fewer women with depressive symptoms than with nondepressed women, 10 studies showed those with symptoms were associated with decreased breastfeeding duration

– Impaired bonding with infant - Prospective study (n > 5000) assessed mothers 9 mo postpartum and found that they were less likely to tell child stories daily, play peekaboo, or read to their child when compared to nondepressed mothers

– Poor child healthcare - Prospective study (n > 5000) showed depressed mothers were less likely to place their infant on their backs to sleep compared to nondepressed mothers, and less likely to vaccinate their children in prospective study of depressed women (n > 800) and nondepressed mothers (n > 4000); 54% of children of depressed mothers were up-to-date at 24mo appt as opposed to 62% of nondepressed mothers

– May also compromise safety practices like using infant care seats appropriately and using electric outlet covers

– Abnormal infant and child development

– Cognitive impairment and psychopathology of the child

– Marital discord

Adverse consequences

– SUICIDE: a leading cause of death

in postnatal women; absolute rate

of suicide during postpartum

period is low at 1 to 5 per 100,000

live births

– Suicide attempts are 44 per

100,000

– Suicidal ideation occurs in ~ 3%

– Clinical assessments revealed very

few were “high risk” as they did not

have active SI with plans, intent, or

access to means

– INFANTICIDE: may be more likely to occur in women who are psychotic or were previously admitted to a psychiatric hospital; 2 to 7 per 100,000

– Mothers who kill their infants often try to kill themselves

– Rumination about harming their baby may be described as “scary thoughts” and are usually revealed through direct questioning

– Thoughts generally experienced as ego dystonic and intrusive

– May indicate patient is psychotic and should prompt evaluation for psychotic symptoms (i.e. delusions or hallucinations)

– Case series of 10 mothers with postpartum depression who killed their infants found that the pregnancy was wanted and the baby was healthy, but these mothers were overwhelmed and reluctant to be left alone with their infant

Differential diagnosis– Normal postpartum changes – somatic symptoms of major depression, such as

changes in sleep, energy level, and appetite, overlap with changes observed in

the postpartum women who are not depressed; must evaluate these changes in

the context of normal expectations in puerperium

– Postpartum blues – dysphoria, insomnia, fatigue, and impaired concentration;

diagnosis does not require a minimum number of symptoms; mild and self-

limiting with onset within 2-3 days of delivery and resolution within two weeks

– Minor depression – requires 2-4 depressive symptoms lasting at least two

weeks; no history of mania or hypomania

– Bipolar disorder – major depression marked by past history of hypomania

and/or mania

– Other psychiatric disorders – psychotic disorders marked by hallucinations

and/or delusions

Assessment – When to suspect

postpartum depression?

– Anxiety about health of infant

– Concerns about one’s ability to care for infant

– Negative perception of infant’s temperament and behavior

– Despondency for at least two weeks

– Lack of interest in the infant’s activities

– Lack of response to support and reassurance

– Using alcohol, illicit drugs, or tobacco

– Nonadherence to postnatal care

– Frequent nonroutine visits with or telephone calls to the OB or pediatrician

– EPDS score of 12 or above yields 80% sensitivity and 90% specificity for major depression, and 20 and above is recognized as severe depression

Screening tools

– Edinburgh Postnatal Depression Scale (EPDS) is most frequently used in research setting and clinical practice with a sensitivity/specificity 80 to 90%

– Translated into 50 languages, 10 self-reported questions, healthy literacy appropriate, <5 min to complete, includes anxiety symptoms, but excludes constitutional symptoms (loss of sleep) that are common in postpartum period

– Inclusion in other screening instruments (Patient Health Questionnaire 9, Beck Depression Inventory, Center for Epidemiologic Studies Depression Scale) reduces specificity for perinatal depression

– Most have 20 questions and require more time to complete and score

– Part of screening process is to counsel about risk of developing depressive syndrome and teach mother to recognize early symptoms and seek appropriate intervention

– Results of any screening instrument should be interpreted within clinical context

Treatment

– Initiation of treatment or referral to mental health care providers offers

maximum benefit

– Obstetric care providers should be prepared to initiate medical therapy, refer to

appropriate behavioral health resources when indicated, or both

– Collaborative care models implemented in obstetrics and gynecology offices

improve long-term patient outcomes

– Systems should be in place to ensure follow-up for diagnosis and treatment

Mild to moderate perinatal depression

– Psychotherapy – beneficial to breastfeeding mothers who do not wish to expose their infants to antidepressants

– Antidepressants – if psychotherapy is not available, not successful, or is declined, or patient had a previous response to antidepressants

– SSRIs, SNRIs, bupropion, mirtazapine

– Benefits to antidepressant therapy outweigh potential risks to infant

– Combination therapy

– Most patient prefer combination therapy; study (n = 100) found that pharmacotherapy plus psychotherapy was preferred by 55%

Treatment

Severe perinatal depresson

– Usually report suicidal ideation and

manifest poor judgment placing

the patient and others at risk for

imminent harm

– Referral to psychiatric

management with possible

hospitalization

– Online resources

– U.S. Department of Health and Human Services Office of Women’s Health: http://www.womenshealth.gov

– MentalHealth.gov: http://www.mentalhealth.gov

– National Institute of Mental Health: http://www.nimh.nih.gov/

– Online support groups

– Postpartum Support International online meetings: http://www.postpartum.net/get-help/psi-online-support-meetings/

– Smart Patients Postpartum Community: https://www.smartpatients.com/partners/ppd

– What to Expect Postpartum Depression: https://www.whattoexpect.com/first-year/postpartum-depression (click on forums)

– Baby Talk – education on what to expect antepartum, intrapartum, and postpartum

– Wesley Lactation Clinic – available to those who deliver at WMC

Additional support

Additional support

The Village Perinatal Support Network

– Mission: “Build community awareness through advocacy and education, and to

promote social support and treatment of mental health issues related to

childbearing throughout Southern Kansas.”

– Website: http://monarchks.org/thevillageict/

– Facebook:

https://www.facebook.com/pg/TheVillageICT/about/?ref=page_internal

– Phone: 316.272.0072

Conclusion

– Perinatal depression is a common complication of pregnancy with potentially

devastating consequences if it goes unrecognized and untreated

– Screening alone has clinical benefits, although initiation of treatment or referral

to mental health care providers offers maximum health benefits

– Systems should be in place to ensure follow-up for diagnosis and treatment

– Obstetric care providers should screen patients at least once in the perinatal

period, and if screened during pregnancy, additional screening should occur

during comprehensive postpartum visit

– Women should ideally have contact with a maternal care provider within first

three weeks postpartum through a visit, phone call, text, or app-based support

What makes it all worth it…

References

– https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression

– https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

– https://www.uptodate.com/contents/bipolar-disorder-in-postpartum-women-epidemiology-clinical-features-assessment-and-diagnosis

– https://www.uptodate.com/contents/postpartum-unipolar-major-depression-epidemiology-clinical-features-assessment-and-diagnosis

– https://www.uptodate.com/contents/mild-to-moderate-postpartum-unipolar-major-depression-treatment