Transcript Document

California Parenting Institute
Santa Rosa, CA
Grace Harris, MFT
Why “Perinatal Mood Disorder”
vs. “Postpartum Depression”?
PMD includes other Mental Health diagnoses:
Depression / Anxiety / OCD / Panic Disorders,
Agoraphobia / Bi- Polar Disorder / Psychosis / PTSD
PMD occurs before, during & up to 12 months postpartum.
(Also PMAD – Peri Natal Mood & Anxiety Disorders)
Why is this important?
• Postpartum Depression is highly prevalent
• Postpartum Depression is not time-limited
• Postpartum Depression is a major risk factor for an infant’s
development
• Postpartum Depression IS HIGHLY TREATABLE
• Postpartum Depression does not get treated
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Prevalence of Depression*
Data collected from 17 states through the Pregnancy Risk
Assessment Monitoring System (PRAMS) revealed that
11-20% of women experienced postpartum depression.
The Agency for Healthcare Research and Quality reports
the prevalence for depression during pregnancy as 1423%.
* No data available on Perinatal Mood Disorder
Prevalence
Major depression during pregnancy:
9 -13 % of U.S. Women
(Gaynes et al. 2005, AHRQ)
Major depression postpartum:
7 % of U.S. women in the first 3 months
22 % of U.S. women in the first 12 months
10% of fathers develop depression within the first year
after the birth of a child
(Gaynes et al. 2005, AHRQ)
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Kaiser Small Test of Change
 Started with small group of pediatricians – voluntary
participation (Sonoma County – Santa Rosa facility)
 Used PHQ-9
 Rate of depression first trial 19%
 Now screening is routine (pediatrics, gynecology and
other departments)
 Rate is close to 20%
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Major and Minor Depression in Pregnancy ACOG VOL. 113, NO. 6, JUNE 2009
Prevalence
Type
Prenatal
depression
Onset
maternal depression
and related symptoms
Prevalence
During pregnancy 10 to 20 percent
of pregnant
mothers
Symptoms
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•
•
•
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Crying, weepiness
Sleep problems
Fatigue
Appetite disturbance
Anhedonia
Anxiety
Poor fetal attachment
Irritability
Prevalence
Type
Baby Blues
Onset
maternal depression
and related symptoms
Prevalence
Begins during the As high as 80
first few weeks
percent of new
after delivery
mothers
(usually in first
week, peaking at
3-5 days).
Symptoms
usually resolve by
two weeks after
pregnancy.
Symptoms
•
•
•
•
•
•
•
•
•
Crying, weepiness
Sadness
Irritability
Exaggerated sense of
empathy
Anxiety
Mood lability (“ups” and
“downs”)
Feeling overwhelmed
Insomnia, trouble falling
or staying asleep;
fatigue/exhaustion
Frustration
Prevalence
Type
Onset
Postpartum Usually within
depression the first two to
three months
post-partum,
though onset
can be
immediate after
delivery
(distinguishable
from “baby
blues” as it lasts
beyond two
weeks postpartum)
maternal depression
and related symptoms
Prevalence
10 to 20
percent of
new mothers
Symptoms
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Persistent sadness
Frequent crying, even about little things
Poor concentration
Difficulty remembering things
Feelings of worthlessness, inadequacy or guilt
Irritability, crankiness
Loss of interest in caring for oneself
Not feeling up to doing everyday tasks
Psychomotor agitation or retardation
Fatigue, loss of energy
Insomnia or hyperinsomnia
Significant decrease or increase in appetite
Anxiety manifested as bizarre thoughts and fears,
such as obsessive thoughts of harm to the baby
Feeling overwhelmed
Somatic symptoms (headaches, chest pains, heart
palpitations, numbness and hyperventilation)
Poor bonding with the baby (no attachments), lack
of interest in the baby, family or activities
Loss of pleasure or interest in doing things one
used to enjoy (including sex)
Recurrent thoughts of death or suicide
Prevalence of other high risk conditions routinely
screened:
 Gestational Diabetes 4.6%
 Hypertension 5%
Detection of ante natal depression
without formal screening:
 6% with standard care
 34% with Edinburgh Postnatal
Depression Scale
Paternal Peri-Natal Depression
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Research at Easton Virginia Medical School
28,000 male and female subjects
Women 24 %
Men 10.4% (compared to typical rate of 4.8%)
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RISK FACTORS
Amanda is 24 years old. She has a history substance abuse. Both she
and her partner entered treatment when she learned she was
pregnant. She has a 3 month old girl. She has a history of bipolar
disorder which was previously controlled well with medication.
However, she really wants to breast feed her baby and is worried
about the medication’s effects so she is not taking it right now.
She is trying hard to be a good mom but is very worried that she “will
do the wrong thing.” She is feeling isolated because she can’t talk to
old friends who are still using and her partner spends a lot of time
going to NA meetings because he seriously is trying to stay clean.
She is willing to talk to a doctor about resuming medication and
accepted a referral to a baby gym class. She also put her name on a list
to receive subsidized housing so hopes she and her partner can move
in 6 months to a year.
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RISK FACTORS
Maricela is a 29 year old monolingual Latina living with her
partner and her 5 year old son from a previous relationship
and her new baby girl. Her father recently died in Mexico.
She was unable to attend the funeral due to finances.
She reported being depressed after her last delivery and
scored 16 on the EPDS which is in the clinical range. She has
difficulty sleeping and worries about the baby. Recently she
told her partner she had been sexually abused as a child and
her mother told her she just had to live with it. There was IPV
in her previous relationship.
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Risk Factors
 Biological Vulnerability
 Psychological Factors
 Life Stressors
Biology
 Rule out other medical problems –
anemia, thyroid deficiency
 Hormone fluctuations including
stress hormones
 Fatigue
 Prior history of depression
Psychology / Life Stressors
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Biology / Psychology
 Women who have never been depressed:
 10% develop PPD
 Women who have been depressed:
 25% develop PPD
 Women with previous PPD:
 50% develop PPD
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Mother – Child – Family
Mother
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Suffering
Lack of joy in child
Lack of confidence in parenting ability
Missed work
Social withdrawal
Somatic symptoms
Guilt
Suicidality
Father
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Increased anger/conflict with others
Increased use of alcohol/drugs – misuse of Rx
Isolated from family
Feeling discouraged
Impulsive – reckless driving, extra-marital relationship
Physical problems – headaches, indigestion
Work constantly or worry about performance at work
Conflict between how he thinks he should be as a man and
how he actually is
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Family
 Marital discord
 Withdrawal from other family members
 Challenging relationship with other
children
PMD affects pregnancy outcomes
↑ preterm birth
↑ low birth weight
↑ miscarriage
↑ preeclampsia
Research suggests maternal depression leads to an alteration in the mother’s
neuroendocrine axis and uterine blood flow which may contribute to premature
delivery, LBW etc.
Babies of mothers who suffered from depression during pregnancy have elevated
cortisol and catecholamine levels at birth. They cry more often and are more
difficult to console.
Marcus, S., & Heringhausen, J. (2009). Depression in Childbearing Women: When
Depression Complicates Pregnancy. National Institute of Health. Primary Care, March 2009.
PMD & BIRTHWEIGHT
 Wright State University School of Medicine Study
Boonshoft School of Medicine 2009 (Kohake, Paton
and Heis)
 Maternal age and trimester entry into prenatal care not statistically
significant relative to infant birth weight.
 EPDS score and maternal race was statistically significant relative to
EPDS score.
 Future studies should quantify if antenatal depression existed with low
birth weight infants.
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Health Care Consequences
INFANT CARE
- Less frequent HSV
- More urgent care/ER
- Ineffective Anticipatory Guidance
- Behind on Immunizations
Do babies have mental health?
Infant Mental Health
 Relationships are central to infant mental health
 Social-emotional capacities depend on love and care
 Trusting and caring by the primary caregiver is the
foundation for later development.
 Social development includes ability to form
relationships and knowledge of social rules and
standards
 Emotional development includes experience of
feelings about self and others.
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Impact of maternal depression on developing child
When compared to non-depressed mothers,
depressed mothers demonstrate:
*Less affectionate behaviors
*Less responsive to infant cues
*More flat affect or withdrawal
Infants display more sleep problems
which further exacerbates mother’s difficulties
As studies continue - effects on child may extend well into early teen years
and have continued repercussions
Paternal depression has shown a strong link to future mental health
problems in children
Impact of maternal depression on developing child

PMD directly impacts the infant’s experience
and current studies indicate negative
consequences on development
• Social
• Emotional
• Cognitive
• Language
• Attention
• Mother/Father-Infant Relationship/ Interaction
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Maternal Depression and the Developing Child
“Children who experience maternal depression early in life may
suffer lasting effects on their brain architecture and persistent
disruptions of their stress response systems”.
Maternal Depression Can Undermine the Development of Young Children (2009). Working paper 8, Center on the
Developing Child Harvard University. December 2009.
Studies of children of depressed mothers show patterns of brain activity (in
EEG) that is similar to what is found in adults with depression. The patterns
are more pervasive with the mother is both depressed and withdrawn from
her infant
Why use a validated screening tool?
 to increases diagnostic reliability
EPDS increased the detection of PPD from 6.3% to 35.4% (Evins et.al, 2000)
Why screen universally?
 to identify women who would otherwise go
undiagnosed - including those with suicidal
ideation
In a sample of women 6 wks PP, the diagnosis of PPD increased from 3.7%
to 10.7% with routine screening. (Georgiopoulous et. al. 2001)
Who Knew?
Among women who were
screened and identified as
depressed, less than half report
that they recognized their
depression.
Who should screen?
Every health care provider that interacts
with women of childbearing age ….
 Mental Health Providers
 Family Practice
 OB/Gyn
 Pediatricians
 Internists
 Community Health Workers
 Others including social service providers
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Validated Screening Tools
Edinburgh (EPDS)
10 questions – available in Spanish and 20 other languages.
Patient Health Questionnaire (PHQ)
9 questions
Postpartum Depression Screening Scale (PDSS)
35 questions
2-question screen:
 During the past month, have you often been bothered by feeling down,
depressed, or hopeless?
 During the past month, have you often been bothered by little Interest or
pleasure in doing things?
DID YOU KNOW?
The American Academy of Obstetrics and Gynecology recommends the
screening of pregnant women for depression at least once per
trimester, using a simple two question screening tool
Two question screen:
 During the past month, have you often been bothered
by feeling down, depressed or hopeless?
 During the past month,
have you often been
bothered by little
interest or pleasure in
doing things?
Protective Factors
Blanca is a 27 year old Latina who following the birth of her fourth child became very anxious and wasn’t
able to sit still. She was referred by WIC. She scored 22 on the EPDS with many responses indicating
anxiety or worry. She also mentioned thoughts to harm herself, but agreed to contract for safety. Her
family is supportive and she says she feels comfortable in her mom’s home.
When the symptoms became too much for her she accepted a referral to the county Psychiatric
Emergency Services and received a prescription for an antidepressant. She had been offered medication
before, but felt that the doctor hadn’t really listened to her and simply gave medication. She felt that
the county doctor paid attention to her before he prescribed so she was willing to try medication. She
began to feel better and began to sleep.
She then disclosed that she was having problems with her partner who began seeing another woman
when Blanca was pregnant. He also had a problem with alcohol which affected his ability to hold a job.
Her family supported her decision to leave him and she is grieving the loss of the 10 year relationship. At
the same time she is thinking to a future where she might get some training at the local community
college and get a job in the medical field. Blanca has 4 sisters and they spend time with her and her
children or invite her to their homes during the day. Her mother read the brochure we gave Blanca
about peri-natal depression and she has also become more understanding.
Support – Increased Protective Factors
1. Parental Resilience
2. Social Connections
3. Knowledge of Parenting & Child Development
4. Concrete Support in Times of Need
5. Social and Emotional Competence of Children
www.strengtheningfamilies.net
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Counseling
 *Interpersonal Therapy
 Cognitive Behavioral Therapy
 *Couples Therapy
*focus on quality of relationships
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Medication
Antidepressants
“The research suggests safest choices for
breastfeeding mothers include the SSRI sertialine and
the tri-cyclic antidepressant nortiptyline”
www.womenshealth.org
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University of Illinois at Chicago (UIC)
Perinatal Consultation Service
 1-800-573-6121
 The UIC Perinatal Consultation Service assists health professionals by
answering questions they have concerning screening, assessing and
treating women with mental health issues during pregnancy and
postpartum.
 Detailed information about effects of antidepressant medications during
pregnancy and breastfeeding
 Perinatal anxiety disorders
 The impact of perinatal mental health issues on the mother-infant
relationship.
The service is sponsored by a grant from the Illinois Department of Healthcare and Family
Services.
 HANDOUT ON PERINATAL ANTIDEPRESSANTS
Electroconvulsive Therapy
Effective and works faster than drugs
 Severe depression
 Postpartum psychosis
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Alternate Therapies
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Light box
Alternative medicines/practices
Infant massage
Increased exercise
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Recovery from PMD
 How long before receiving help?
 How severe are symptoms?
 How effective is the treatment?
(Medication/Therapist)
 What is current life situation?
 How active in self care and following
treatment?
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Barriers to Treatment
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Public Awareness
Stigma
Professional Education
System Barriers
Resources
System Linkages
Let’s also think about dads here!
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Stigma & PMD
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Education
Culture – Expectations and Experiences
Relationships! Other moms, spouse, parents
Time of Onset – immediately post-partum vs. 8
months post-partum
 Messages from Health Care Professionals
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Stigma
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STIGMA CONVERSTION
 1938 law in Great Britain
 Andrea Yates
 Infanticide in first year postpartum
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Community Education & Advocacy
To increase awareness and understanding of PMD
 Reduce stigma – more acceptance of PMD
and possible occurrence over pre and long
post-natal period.
 Capacity building – more providers paying
attention to mood disorders during
pregnancy and during 1st year of infancy.
 Increase 1:1 and group treatment
at community health clinics.
Our Community
Sonoma County, CA
 In 2002 our county convened a group of community
providers involved in the care of children aged 0-5
with a focus on mental health concerns, the
Children’s Mental Health Partnership.
 A sub committee of this group eventually became the
Peri Natal Mental Health Partnership.
 Partners include Public Health Nursing, Hospitals,
physicians, parenting professionals and both agency
and private practice therapists.
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CPI Model
 Mental Health Services Act (CA Prop 63) Prevention
and Early Intervention
 Home Visits for mothers experiencing PMD –
Therapist and/or therapist intern.
 Parent Support for parents of children 0-5 (Triple P
Level 3 or 4)
 Peri Natal Mental Health Partnership
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Services Provided Year One
 44 mothers identified with a peri natal mood disorder received
home visits. Average number of visits per mother = 6. Some
mothers received visits for up to 6 months and other mothers
were referred for medication and other counseling services so had
less visits.
 An additional 33 mothers with other mental health concerns that
affected parenting received home visits, assessments and
referrals.
 We have one 32 hour bilingual supervising licensed therapist on
staff for this project. We use interns and trainees when possible in
order to see more families.
 Common sources of referrals: Public Health Nursing, CPI Parent
Educators, WIC, clinic doctors and nurse practitioners, hospital
social workers.
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Community Education
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Policy and Politics
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Melanie Blocker Stokes
MOTHERS ACT
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Federal Mandate
Part of Healthcare Reform Initiative
Expand research on Postpartum conditions
Expand longitudinal studies of mental health
consequences
 Allows grants for services to individuals with a
postpartum condition and their families
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Resources / Handouts
Handouts
UIC Perinatal Antidepressants Information
Perinatal Mental Health Partnership of Sonoma
County, CA – Action Plan
Sample Moms Newsletter
Web Sites are easy to find in Search
www.postpartumprogress.com
www.postpartumdads.org
www.postpartum.net
www.helpguide.org
www.jennyslight.org
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Contact
GRACE HARRIS, Parent Resources Director
California Parenting Institute
[email protected]
CHARLENE BOCCA, Perinatal Therapist
California Parenting Institute
[email protected]
KAREN CLEMMER, Perinatal Services Coordinator
County of Sonoma
[email protected]
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