By Ricardo J. Fernandez, M.D., DFAPA Councilor, NJ Psychiatric Association
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Transcript of By Ricardo J. Fernandez, M.D., DFAPA Councilor, NJ Psychiatric Association
This presentation is for the exclusive use of the
New Jersey Psychiatric Association website
and for the purposes of consumer information and education.
It may not be otherwise reproduced or presented without the knowledge and consent of
Ricardo J. Fernandez, M.D.
Women are at serious risk for developing a
psychiatric illness after childbirth.
D. Wolocko, Daily News
Postpartum mothers are at significant risk of developing a
psychiatric illness severe enough to require
hospitalization as the next slide demonstrates.
This increased risk lasts for about two years after
childbirth.
Admissions to a Psychiatric Hospital:2 Years Pre and Post Delivery
Kendell RE et al. Br J Psychiatry. 1987;150:662; presented at WMH, Berlin 2001.
0
10
20
30
40
50
60
70
Ad
mis
sio
ns
/Mo
nth
Pregnancy
–2 Years – 1 Year Childbirth +1 Year +2 Years
“Postpartum Depression” is a general term used in our society to describe any psychiatric illness
occurring after childbirth.
In reality, Postpartum Depression
describes only one of four syndromes that can
occur after childbirth.
The four syndromes are:
• Maternity or Postpartum Blues
• Postpartum Psychosis
• Adjustment Disorder of the Postpartum Period
• Major Depression in the Postpartum (Postpartum Depression)
Unfortunately, common reference to all four conditions as
“Postpartum Depression” creates confusion and fear.
It is important to understand that Postpartum Psychosis, the most severe and dangerous condition,
is relatively rare and quite different from Postpartum
Depression, as the next slide demonstrates.
Cohen LS. Depress Anxiety. 1998:1:18-26.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Transient, Transient, nonpathologicnonpathologic
Medical Medical emergencyemergency
Serious, Serious, disablingdisabling
Postpartum BluesPostpartum Blues
Postpartum DepressionPostpartum Depression
Postpartum PsychosisPostpartum Psychosis
50% to 70%
10%
0.01%
2/3 have onset by 6 wks postpartum
risk for Postpartum Depression
70% are affective (Bipolar, Major
Depression)
Spectrum of Postpartum Mood Changes
Incidence
Incidence
Postpartum Psychosis is often mislabeled
in the media as Postpartum Depression, creating much anxiety and fear in women with
the less severe postpartum disorders.
Maternity or Postpartum Blues
• Is not considered a psychiatric illness and is unrelated to psychiatric history .
• Occurs in 26 to 85% of birthing mothers. The exact incidence is unclear.
• Present in all cultures studied• Appears unrelated to environmental
stressors
Maternity or Postpartum Blues
“Blues” = heightened reactivity, not clinical
depression• Mood swings from weepiness to extreme
happiness and heightened reactivity • Occurs 3 to 5 days after childbirth. It is
self limiting, resolving in about a week.• If occurs, increases risk for
Postpartum Depression.
The rest of the syndromes to be described are
all considered psychiatric illnesses and benefit from clinical
treatment.
Postpartum Psychosis
• Is relatively rare, occurring one to three cases per 1000 births
• Is a severe and life threatening condition for both mother and infant
• Develops soon after birth, often within two weeks, usually within a month
• Requires intense treatment and hospitalization: A medical emergency
• Is usually followed by Postpartum Depression
Symptoms of Postpartum Psychosis
• Delusions: False beliefs, often of a religious nature and very frequently involving the infant
• Perceptual distortions: Seeing or hearing things which are not present
• Often, feelings of excessive well being or importance
Adjustment Disorder of the Postpartum Period
• Occurs in about 20% of birthing mothers but incidence is unclear as many women with this problem do not seek treatment.
• Manifests as excessive difficulties adjusting to motherhood.
• If emotional symptoms exist, they are not as severe as those seen in Postpartum Depression
Bright. Am Fam Physician. 1994; 50: 595.Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Adjustment Disorder of the Postpartum Period
• Can resolve without treatment over time but can cause ongoing difficulties for the mother.
• Can develop into Postpartum Depression if more severe and untreated.
• Responds well to short term psychotherapy.
Bright. Am Fam Physician. 1994; 50: 595.Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Postpartum Depression
• Occurs in 10% of birthing mothers– 20% if the mother has had Maternity
Blues.
• Occurs usually within 6 weeks of birth but can occur up to a year after birth
Bright. Am Fam Physician. 1994; 50: 595.Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Onset of Symptoms in Postpartum Depression
Two Studies
2. Time of Onset of Postpartum Depression in 413 Patients
The more severe, the earlier the onset.
0
20
40
60
Within Two Weeks Six Weeks Six Months
Per
cent
age
of P
atie
nts Severe, needed hospital admission
Mild, treated by general practitioner
1. Time of Onset of Postpartum Depression in 315 WomenWithin 14 Days
46%Within 6 Weeks
14%
Within 3 Months
22%Within 6 Months
18%
Postpartum Depression: Symptom Onset
• 40%: After first postnatal visit – At 6 weeks
• 20%: Coincided with weaning
• 16%: At return of menstruation– At 2 to 3 months if not breast feeding
• 14%: Initiation of oral contraceptives
Postpartum Depression
• Manifests as symptoms of depression, often with marked anxiety/agitation and obsessions about harm coming to the child.
• Can develop gradually or abruptly after birth
Bright. Am Fam Physician. 1994; 50: 595.Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
What are the symptoms of Depression?
– Sadness of mood most of the day, nearly every day
– Diminished interest or pleasure in usual activities
– Major change in appetite or weight– Not able to sleep or sleeping too much– Agitation or feeling slowed down– Fatigue or loss of energy– Feelings of worthlessness or excessive or inappropriate
guilt– Diminished ability to think or concentrate, or
indecisiveness– Recurrent thoughts of death, dying, or suicide
APA Diagnostic and Statistical Manual. 1994
Symptoms Frequently Seen in
Postpartum Depression
• Marked agitation and anxiety
• Mother can not sleep even when the baby is sleeping
• Obsessions and compulsions about the baby
What are obsessions and compulsions?
• An obsession is a repetitive, intrusive and disturbing thought that enters the mind and is out of the individual's control.
• A compulsion is a repetitive act that is done in an attempt to be rid of the obsessional thought.
• Both cause great anxiety and discomfort in the individual.
Postpartum obsessions
• Commonly focused on infant• Thoughts(obsessions) of hurting the
infant– Dropping infant– Drowning infant– Stabbing infant– Putting infant in oven or microwave– Sexually abusing infant– Thoughts that someone will steal or
harm the infant
Postpartum compulsions
• Commonly follow the obsessions as an attempt to alleviate the thought– Avoid holding baby by staircases, etc– Avoid bathing infant– Hide knives– Avoid kitchen area– Avoid changing diapers or bathing infant– Avoid leaving the house
Although the presence of obsessions and compulsions
indicates need for treatment, these mothers are rarely
dangerous to the infants. They are actually at higher risk to hurt
themselves as a result of their fear of possibly hurting the infant.
How is Postpartum Depression treated?
• Psychiatric medication– Antidepressants:
• In particular, those that increase release of serotonin in the brain
– Medicines for anxiety and to help with sleep
• Individual, couples and family psychotherapy
What about breast feeding?
The incidence of breast feeding in birthing mothers
is increasing as the next slide shows.
Incidence of Breast Feeding 1926-2001
80%
49%
28%20%
37%
52%
67%61%
1926-1930
1951-1955
1966-1970
1972 1975 1998 2000 2001
Briggs, Freeman, Yafee, Drugs in Pregnancy and Lactation, 1998
Maternity Survey, Parents Express, Phil.,PA., 4/01, 4/02
……a reasonable a reasonable optionoption
in Postpartum in Postpartum Depression ? Depression ?
Breast feeding…Breast feeding…
Although all medications cross into breast milk,
there are a few antidepressants that
appear to cross less than others and may be safer
in breast feeding. Consult your doctor.
Risk Factors
• First pregnancy• Young age• Psychiatric illness during pregnancy • Prior history of postpartum illness• Prior history of mental illness• Family history of mental illness• Recent stressful life events• Problems in the marriage
In addition, there are many societal and
cultural factors that may predispose women to postpartum problems
including...
In summary, postpartum psychiatric illness exists.
It can be debilitating and dangerous to both mother
and child. Effective treatments are
available. Support groups of mothers in recovery are also
available in many areas of the country.
For more information:
• Consult with your doctor• Contact:
– Depression-After-Delivery (DAD)• www.DepressionAfterDelivery.com
– Depression and Bipolar Support Alliance (DBSA)• Phone: 800-826-3632• Web:www.DBSAlliance.org
– New Jersey Psychiatric Association• Phone: 800-345-0143