Learning Objectives   To identify the spectrum of peripartum mood disorders, their features, diagnostic criteria, and treatments.  To review FDA pregnancy safety categories and lactation categories for commonly prescribed mood medications.  To identify the role of family physicians in identifying and treating peripartum mood disorders

Hirsh Cokenakes, MD, Sarah Elizabeth

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Thomas Jefferson University Jefferson Digital Commons Department of Family & Community Medicine Presentations and Grand Rounds Department of Family & Community Medicine 2-18-2021 Perinatal Maternal Mood Disorders Sarah Elizabeth Hirsh Cokenakes, MD Thomas Jefferson University Follow this and additional works at: https://jdc.jefferson.edu/fmlectures  Part of the Family Medicine Commons, Obstetrics and Gynecology Commons, and the Primary Care Commons Let us know how access to this document benefits you Recommended Citation Hirsh Cokenakes, MD, Sarah Elizabeth, "Perinatal Maternal Mood Disorders" (2021). Department of Family & Community Medicine Presentations and Grand Rounds. Paper 470. https://jdc.jefferson.edu/fmlectures/470 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Department of Family & Community Medicine Presentations and Grand Rounds by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Perinatal Maternal Mood DisordersSarah Elizabeth Hirsh Cokenakes MD, PGY3DisclosuresLearning Objectives 1. To identify the spectrum of peripartum mood disorders, their features, diagnostic criteria, and treatments. 2. To review FDA pregnancy safety categories and lactation categories for commonly prescribed mood medications. 3. To identify the role of family physicians in identifying and treating peripartum mood disorders. Definitions “Baby blues” = feelings of depression or anxiety that start soon after delivery and generally self-resolve without intervention within 2 weeks. 6Postpartum depression (PPD) = minor depressive symptoms or unipolar major depressive disorder occurring during pregnancy or in the 4 weeks (academic definition) - 12 months (used in clinical practice) after delivery. 2Postpartum anxiety (PPA) = anxiety disorders, including OCD, present in the perinatal period. 2Postpartum psychosis (PPP) = disorganization, hallucinations, and/or bizarre behavior that occurs within 4 weeks of delivery. 14Relevance to primary care and the role of family medicine: Role of Family Medicine  Approximately ⅓ of pregnant women in the U.S. have received some form of care (prenatal or otherwise) from a family medicine physician in the past year. 5Family medicine providers see patients in the preconception phase when they can identify potential risk factors for perinatal mood disorders and optimize management.Family medicine providers see infants for more frequent visits after birth, presenting opportunities to also check in with new parents.  Epidemiology and Natural Course of the “Baby Blues” In a systematic review and meta analysis of publications from three international databases, authors found that the prevalence of “baby blues” was around 39%. 8The term, “baby blues,” is frequently used to describe a constellation of symptoms including anxiety, sadness, irritability, sleep disturbances, appetite changes, confusion and fatigue that most commonly begins 2-5 days after delivery and persists for no more than 2 weeks. 9Important to note, “baby blues,” does not impair daily functioning or ability to care for the baby and resolves without treatment. 9Case #1: Beatrice  Case #1 Beatrice is a 24y/o G4P4 with PMH MDD (on no meds in pregnancy), gHTN who sees you in the office 3 weeks postpartum for an infant weight check. She is accompanied by her 3 other children, all of whom are screaming when you enter the exam room. She expresses concern that she will not be able to figure out how to get her newborn insurance by the time he is 1 month old. She currently has Keystone First. What risk factors does this patient have for developing postpartum depression? Epidemiology of Postpartum Depression  World-wide rates of PPD vary significantly.1 ● High-income countries (including the U.S.): 7-13%● Low/Middle-income countries: 20% Risk factors for developing PPD include: 2● History of prior mood disorder ● Family history of PPD ● Poor support systems Reference 2 Case #1 Beatrice is a 24y/o G4P4 with PMH MDD (on no meds in pregnancy), gHTN who sees you in the office 3 weeks postpartum for an infant weight check. She is accompanied by her 3 other children, all of whom are screaming when you enter the exam room. She expresses concern that she will not be able to figure out how to get her newborn insurance by the time he is 1 month old. She currently has Keystone First. What risk factors does this patient have for developing postpartum depression? Epidemiology of Postpartum Depression  One U.S. study estimated that 27% of PPD begins pre-pregnancy and 33% of PPD begins during pregnancy. 3Poor identification and measurement of symptoms in pregnancy may lead to women being classified as having postpartum onset of symptoms as opposed to peripartum onset of symptoms. Some evidence suggests that depressive symptoms may actually be more prevalent during pregnancy than after delivery. 4Pathophysiology: Possible Role of Reproductive Hormones in PPD Although most risk factors for PPD are not necessarily specific to the perinatal period, there is some evidence that suggests the existence of a subtype of PDD characterized by sensitivity to fluctuating reproductive hormone levels. 2Rapid changes in estradiol and progesterone following delivery can trigger the onset of symptoms in susceptible women with this phenotype. 9Low levels of oxytocin in the third trimester are correlated with increased depressive sx during pregnancy and after delivery. 9Screening and Diagnosis of Postpartum Depression DSM5 Criteria for diagnosis = a major depressive episode with peripartum onset. 9 Five depressive symptoms (below) must be present for at least 2 weeks: ● Depressed mood present most of day ● Loss of interest or pleasure ● Insomnia or hypersomnia ● Psychomotor retardation or agitation ● Worthlessness or guilt● Lack of energy/fatigue ● Impaired concentration/ indecisiveness● Weight or appetite change● Suicidal ideation Treatment of Postpartum Depression  Mild-Moderate Postpartum Depression ● Psychotherapy is first line. 9 Moderate-Severe Postpartum Depression● Combination of psychotherapy and pharmacotherapy is first line. 9  ● SSRIs,  SNRIs, Mirtazapine (minimum 6-12 months) ● ECT for those who fail 4 consecutive medication trials, particularly helpful in settings of psychosis, plans for suicide/infanticide, refusal to eat. ● IV Brexanalone for those who fail ECT, decline. Medication Risks in the Peripartum Period FDA Pregnancy Categories:A - adequate studies have not shown risk to fetus in the first trimester (or beyond). B - animal studies have shown no risk to fetus. No data from human studies. C - adverse effects in animal studies. No data from human studies. Benefits > risks. D - evidence of fetal risk based on investigational or marketing studies in humans. Benefits may warrant use in certain situations. X -  evidence of fetal risk based on investigational or marketing studies in humans. Risks > Benefits Lactation Risk Categories:L1 - no demonstrated risk to infant in controlled studies. L2 - studied in limited number of women without adverse effects in infants. L3 - No controlled studies in breastfeeding women. Risk is possible.  L4 - Evidence of risk in breastfed infants. Benefits may warrant use in certain situations. L5 - Significant documented risk to infants. Risks > Benefits Antidepressants: Safety During Pregnancy and Breastfeeding 13 Antidepressant FDA Pregnancy CategoryLactation Risk Category Notes Sertraline (Zoloft) C L2 Considered a preferred antidepressant with breastfeeding Fluoxetine (Prozac) C L2/ L3 L2 (older infants) L3 (neonates) Paroxetine (Paxil) D L2 Significant withdrawal syndrome for infants exposed in utero. Citalopram (Celexa) C L3 Citalopram is less compatible with breastfeeding than escitalopram. Escitalopram (Lexapro) C L3 Venlafaxine (Effexor) C L3Antidepressants: Safety During Pregnancy and Breastfeeding 13 Antidepressant FDA Pregnancy CategoryLactation Risk Category Bupropion (Wellbutrin) B L3Mirtazapine (Remeron) C L3Trazodone (Desyrel) C L2Amitriptyline C L2 Nortriptyline (Pamelor) C L2 Duloxetine (Cymbalta) C -Buspirone (Buspar) B L3 Case #2: Ella  Case #2Ella is a 29y/o G1P1 who presents 6 weeks postpartum for her Liletta IUD insertion. Her Edinburgh score is a 9. As you reach for the door knob, she mentions that she has been feeling increasingly panicky over recent weeks. She perseverates frequently over fears that she will drop her new baby. These used to occur only when she was at a significant height or near a ledge, but now these intrusive thoughts occur almost any time she stands up holding the baby. Every time this happens, she reswaddles the baby and readjusts her grip. Which peripartum mood disorder might you be concerned about? Epidemiology of Postpartum Anxiety Disorders The prevalence of PPA has been estimated at approximately 13%, which approximates the prevalence of anxiety disorders in the population at large. 2There appears to be a significantly higher rate of obsessive compulsive disorder in pregnant and postpartum women than in non-pregnant women. 2Risk Factors include: 12 ● Postpartum depression (often co-morbid) ● Past history of mood disorders ● Lack of social support ● Low income/educational attainment Screening and Diagnosis of Postpartum Anxiety An EPDS may flag as positive due to the coexistence of multiple perinatal mood disorders. 2GAD-7 has not been validated for perinatal populations. 11 Other screening tools exist but do not seem to be used in the clinical setting in which we work: 11● Postpartum Specific Anxiety Scale (PSAS) 10○ 51 questions! ● Brief Measure of Worry Severity (BMWS) ○ Examines clinical and personality correlates of severe worriers ● Cambridge Worry Scale (CWS) ○ 16 questions related to pregnancy/birth specific situations ● Pregnancy Related Anxiety Questionnaire Revised (PRAQ-R) ○ Validated only in nulliparous (not parous) women Treatment of Postpartum Anxiety There is a significantly smaller body of research for perinatal mood disorders other than postpartum depression. Thus, most of the treatment methods for postpartum anxiety are extrapolated from the treatment of anxiety during other periods of life. Psychotherapy and medications such as SSRIs are mainstays of therapy. 2Benzodiazepines are considered FDA Class D during pregnancy due to small teratogenic risks in the first trimester and “floppy infant syndrome” if used close to delivery. They are considered L3 risk for breastfeeding. ● ACOG: If benefits > risks, use them! 13  Case #3: Maya Case #3 Maya is a 44y/o G3P3003 with PMH bipolar I (stopped her meds halfway through pregnancy), cHTN, hypothyroidism on Synthroid who sees you in clinic PPD#6 for her infant’s weight check. She presents with her partner, who pulls you aside to confide in you that she is worried about Maya’s behavior. She reports that Maya has been having significant difficulty sleeping since bringing the infant home and yesterday became suddenly paranoid that her partner intended to harm the baby. She has been referencing events that her partner has no recollection of occuring. Which peripartum mood disorder might you be concerned about? Epidemiology of Postpartum Psychosis The prevalence of postpartum psychosis worldwide is approximately 0.2%. 7Filicide rates are approximately 4.5% in those experiencing postpartum psychosis. 7 Risk factors: 14 ● Primiparity ● Advanced maternal age ● History of Bipolar I disorder ● History of Postpartum Psychosis Screening and Diagnosis of Postpartum Psychosis The Mood Disorder Questionnaire (MDQ) is a 5-item screening questionnaire for bipolar disorder, validated for use both during and outside of the peripartum period. Typical onset of PPP is 3-10 days after delivery, and by DSM5 criteria, must occur within 4 weeks of delivery. 14 Presenting symptoms include: 15● Insomnia● Mood fluctuation● Disorganization ● Bizarre behavior ● Hallucinations (tactile, visual, olfactory > auditory) ● Paranoid, grandiose delusions Treatment of Postpartum Psychosis Postpartum psychosis is a psychiatric emergency, and therefore an indication for hospitalization. Women with a history of postpartum psychosis should begin lithium therapy immediately after delivery as prophylaxis. 14Benzodiazepines are used for symptoms of insomnia and agitation in the treatment of PPP. 15 Atypical antipsychotics (Latuda, Abilify) and mood stabilizers can be used for psychotic and manic symptoms in the treatment of PPP. 14 Maintenance treatment with lithium monotherapy is recommended for at least 9 months postpartum to decrease risk of relapse. 15Resources in Philadelphia: Resources in Philadelphia Maternity Care Coalition MoMobile Family Therapy Program:● behavioral health services for low-income pregnant women and mothers with young children (ages 0 to 3).  ● identifies and treats issues of perinatal depression and/or other behavioral health conditions such as PTSD, anxiety disorders, and co-occurring substance dependence. Take Home Points1. There is a wide spectrum of peripartum mood disorders, not just postpartum depression! 2. Mainstays of therapy for both postpartum anxiety and depression include psychotherapy and SSRIs. 3. Postpartum psychosis is a psychiatric emergency warranting inpatient, multidisciplinary treatment. References1. CE Parsons, KS Young, TJ Rochat, ML Kringelbach, A Stein. Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries. Br Med Bull, 101 (2012), pp. 57-792. Louise M Howard, Emma Molyneaux, Cindy-Lee Dennis, Tamsen Rochat, Alan Stein, Jeannette Milgrom. Non-psychotic mental disorders in the perinatal period. The Lancet, Volume 384, Issue 9956, 2014, Pages 1775-1788. 3. KL Wisner, DK Sit, MC McShea, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry, 70 (2013), pp. 490-498. 4. J Heron, TG O'Connor, J Evans, J Golding, V Glover, the ALSPAC Study Team. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord, 80 (2004), pp. 65-73. 5. Kozhimannil, K. B., & Fontaine, P. (2013). Care from family physicians reported by pregnant women in the United States. Annals of family medicine, 11(4), 350–354. https://doi.org/10.1370/afm.15106. ACOG. 2021. FAQ’s: Post-Partum Depression. https://www.acog.org/womens-health/faqs/postpartum-depression 7. Degner Detlef. Differentiating between “baby blues,” severe depression, and psychosis BMJ 2017; 359 :j4692 8. Khadije et al. Systematic Review and Meta-Analysis of the Prevalence of Maternity Blues in the postpartum period. JOGNN  VOLUME 49, ISSUE 2, P127-136, MARCH 01, 2020. 9. Mughal S, Azhar Y, Siddiqui W. Postpartum Depression. [Updated 2020 Nov 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www-ncbi-nlm-nih-gov.proxy1.lib.tju.edu/books/NBK519070/10. Victoria Fallon & Jason Christian Grovenor Halford & Kate Mary Bennett & Joanne Allison Harrold. The Postpartum Specific Anxiety Scale: development and preliminary validation Arch Womens Ment HealthReferences 11. Sinesi, A., Maxwell, M., O'Carroll, R., & Cheyne, H. (2019). Anxiety scales used in pregnancy: systematic review. BJPsych open, 5(1), e5. https://doi.org/10.1192/bjo.2018.7512. Melissa Furtado, Cheryl H.T. Chow, Sawayra Owais, Benicio N. Frey, Ryan J. Van Lieshout. Risk factors of new onset anxiety and anxiety exacerbation in the perinatal period: A systematic review and meta-analysis. Journal of Affective Disorders, Volume 238, 2018, Pages 626-635, ISSN 0165-0327, https://doi.org/10.1016/j.jad.2018.05.073.13. Armstrong, Carrie. ACOG Guidelines on Psychiatric Medication Use During Pregnancy and Lactation. Am Fam Physician. 2008 Sep 15;78(6):772-778. 14. Rodriguez-Cabezas Lisett and Clark Crystal. Psychiatric emergencies in pregnancy and postpartum. Clin Obstet Gynecol. 2018 Sep; 61(3): 615–627.15. Veerle Bergink, Karin M. Burgerhout, Kathelijne M. Koorengeve, Astrid M. Kamperman, Witte J. Hoogendijk, Mijke P. Lambregtse-van den Berg, Steven A. Kushner. Treatment of Psychosis and Mania in the Postpartum Period. The American Journal of Psychiatry. Volume 172, issue 2: 115-123. Feb 1, 2015. There is no ACOG practice bulletin for the management of peripartum mood disorders. 

Perinatal Maternal Mood Disorders

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Perinatal Maternal Mood Disorders

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