Taking Care of the Tree

Chris Raines MSN APRN-BCAssociate Director, Obstetrical Liaison and

Community Outreach

UNC Perinatal Psychiatry Program

Take Care of the Tree Trunk and

the Branches will survive

Care of the TreeHow do you take care of a

TreeWater

NutrientsFertilizer

Protect the RootsSunlight

Care of the TreeHow do we take care of

Ourselves

Mood Disorders in Women in the General Population

Depressive disorders are very common

Lifetime prevalence rates range from 4.9-17.1 percent

Women report a history of major depression at nearly twice the rate of men

Depression is now considered the leading cause of disease-related disability among women in the world.

Women of childbearing age are at high risk for major depression

Perinatal Mood Disorder COMMON

1 in 7 women…15% prevalence rate 4 million women give birth annually in U.S.; ½

million with PPD Most common, complication of perinatal and

postpartum period Compare to prevalence rate of gestational

diabetes at 2-5%

MORBID Devastating consequences for patient and

family low maternal weight gain, preterm birth Impaired bonding between mother and

infant Increased risk of suicide and infanticide

Risk of Relapse of MajorDepression in Pregnancy

High risk of depressive relapse following antidepressant discontinuation during pregnancy ( Cohen et al, JAMA, 2006). Of 201 women in the sample, 86 (43%)

experienced a relapse of major depression during pregnancy.

Women who discontinued medication relapsed more frequently (68% vs 26%) compared to women who maintained medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P<.001).

Pregnancy is not "protective" with respect to risk of relapse of major depression

Care of the TreeWhy do women stop their

medicationsFEAR of harm to the unborn child

Pressure from FamilyMedical Provider tells them to stopI can handle my depression for 9

monthsGUILT

STIGMA

Risks of Untreated Antenatal

Depression Associated with low maternal weight gain,

increased rates of preterm birth, low birth wt, increased smoking, ETOH and other substances

Increased ambivalence about the pregnancy and overall worse health status.

Prenatal exposure to maternal stress has consequences for the development of infant temperament.

Children exposed to perinatal maternal depression have higher cortisol levels than infants of mothers who were not depressed, and this continues through adolescence.

Maternal treatment of depression during pregnancy appears to help normalize infant cortisol levels.

Care of the TreeHow do we take care of

Ourselves

Guilt“Guilt is a cognitive or an emotional experience that occurs when a person realizes or believes-

accurately or not- that he or she has compromised his or her own standards of

conduct or has violated a moral standard” Wikipedia

Care of the TreeHow do we take care of

Ourselves

Stigma“ a set of negative and often

unfair beliefs that a society or group of people have about

something”Merriam-Webster

Documentary

Dark Side of the Full MoonJennifer SillimanMaureen Fura

http://www.youtube.com/watch?v=DyYXhgEhcXg

Treatment

Perinatal Mood DisordersTreatment

One size does not fit all!! Critical for the well being of the

woman ,baby and family Effective treatments are readily available

Psychotherapy Medication Management Other, alternative

Skilled assessment and treatment by mental health professionals in perinatal psychiatry makes a difference in outcomes

Screening Instruments

Edinburgh Postnatal Depression Scale (EPDS) Most commonly employed screening

tool Beck Depression Inventory (BDI) Montgomery-Asberg Depression

Rating Scale (MADRS) Hamilton rating Scale for

Depression (HRSD) Nine Symptom Depression Checklist

of the Patient Health Questionnaire (PHQ)

Edinburgh Postnatal Depression Scale (EPDS)1,2

Ask patient how they have been feeling OVER THE LAST 7 DAYS, not just todayTo use calculator, click on appropriate answer and score appears in box when all

questions completed

1. I have been able to laugh and see the funny side of things *

2. I have looked forward with enjoyment to things *

3. I have blamed myself unnecessarily when things went wrong

4. I have been anxious or worried for no good reason *

5. I have felt scared or panicky for no very good reason

6. Things have been getting on top of me

7. I have been so unhappy, I have had difficulty sleeping

8. I have felt sad and miserable

9. I have been so unhappy that I have been crying

10. The thought of harming myself has occurred to me

* Questions 1, 2, and 4 are scored in reverse order (0-3)

Edinburgh Postnatal Depression Score = /30

3 points - Yes, quite often2 point - Sometimes1 point - Hardly ever

UNC Center for Women’s Mood Disorders:

Perinatal Psychiatry Program

Clinical and Research Programthat provides assessment, treatment and support for women in the perinatal period

Collaboration of doctors, nurses, midwives, therapists, & social workers

www.womensmooddisorders.org

UNC Center for Women’s Mood Disorders:

Perinatal Psychiatry Inpatient Unit 1st free-standing Perinatal Inpatient Unit

in the US—renovated summer 2011 Provides specialized comprehensive

assessment and treatment Medication stabilization Individual and group counseling and

behavioral therapy Partner assisted therapy , maternal-infant

interaction, spirituality, biofeedback, yoga, psycho-education for both patients and spouses

Family therapy

UNC Center for Women’s Mood Disorders:

Perinatal Psychiatry Inpatient Unit Protected sleep times

Gliders and hospital grade pumps, supplies, and refrigerator for milk storage

Specialty perinatal nursing staff State-of-the art treatment Extended visiting hours to maximize

positive mother-baby interaction

UNC Center for Women’s Mood Disorders:

Outpatient Services: Evaluation, Medication Management, and Therapy NP embedded in OB High Risk NP embedded in Peds Clinic Satellite Clinic at Rex Hospital Tele med Psychiatry for outlying rural

Clinics Support group

2nd and 4th Tuesday of each month 6:30-8p-free

References Andrade SE, McPhillips H, Loren D, Raebel MA, et al.

Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf. 2009 Mar;18(3):246-52

Gavin N, Gaynes B, Lohr K, Meltzer-Brody S. et al. 2005 Perinatal depression: a systematic review of prevalence and incidence.Obstet Gynecol. 106:1071-83

Cohen L, Altshuler L, Harlow B, Nonacs R. 2006. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 295(5):499-507

Chambers C, Hernandez-Diaz S, VanMarter L, Werler M. 2006. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med. 354(6):579-87.

Delatte R, Meltzer-Brody S, Cao H, Menard K. 2009 “Universal Screening for Postpartum Depression: An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology, 200(5):e63-4.

Einarson A, Choi J, Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy: results of a large prospective cohort study. Canadian Journal of Psych, 54(4):242-6.

McKenna K, Koren G, Tetelbaum M, Wilton L et al. 2005 Pregnancy outcome of women using atypical antipsychotic drugs: A prospective comparative study. J Clin Psychiatry: 66:444-449.

References Meltzer-Brody S, Payne J, Rubinow D. 2008 Postpartum

Depression: Evolving Etiology & Treatment Considerations, Current Psych, 7(5):87-95.

Meltzer-Brody S, Hartmann K, Miller W, Scott J. 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecology.Obstet Gynecol.104(4):770-776.

Oberlander TF, Warburton W, Misri S et al. 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data. Arch General Psychiatry :63:898-906.

Sit D, Rothschild A, Wisner K. 2006 A Review of Postpartum Psychosis, Journal of Women’s Health: 15(4):352-368.

Viguera A & Cohen L. 1998. The course and management of bipolar disorder during pregnancy. Psychopharmacology Bulletin 34:339-353.

Viguera A, Cohen L et al. 2002 Managing bipolar disorder during pregnancy: weighing the risks and benefits. Can J Psychiatry. 2002 Jun;47(5):426-436.

Webb R, Abel K, et al. 2005 Mortality in Offspring of Parents with Psychotic Disorders: A Critical Review and Meta-Analysis, Am J Psych:162:1045-1056

Yonkers K, Wisner K, Stowe Z, et al. 2004. Management of Bipolar Disorder during pregnancy and the postpartum period. Am J Psychiatry:161:608-620