Perinatal Mood & Anxiety Disorders: Impact, Prevention & Treatment
Perinatal Mood & AnxietyDisorders: Impact,Prevention & TreatmentAmy-Rose White LCSW- Copyright 20171
Amy-Rose White LCSW Utah Maternal MentalHealth CollaborativePerinatal PsychotherapistPrivate practice(541) 337-4960arwhitelcsw@gmail.comAmy-Rose White LCSW- Copyright 20172
3Session Objectives!Understand the symptoms,prevalence and impact of mood &anxiety disorders on new moms!Provide prevention strategies andtreatment optionsAmy-Rose White LCSW- Copyright 2017
4Utah Maternal Mental HealthCollaborative! UtahResources! UtahPSI Chapter! Multi-agencystakeholders! Ideas, information! Projectexchangedevelopment! Socialsupport! Policychange/AdvocacyAmy-Rose White LCSW- Copyright 2017
5Defining the issue:What is Maternal Mental Health?Perinatal Mood, Anxiety, andPsychotic disordersWhy is it relevant in primary &obstetric care?Amy-Rose White LCSW- Copyright 2017
Issues in primary, obstetric, andpediatric care!ICD-10!DSM V!Who is the patient?!Little mental health training!Lack of familiarity with perinatal literature!Separation medical and mental health!Personal bias!Stigma
Whatdidn’t we learn ingraduate education?!No perinatal mental healthtraining programs in US!DSM makes little/nodistinction betweenperinatal psychiatric illnessand others!“Postpartum Onset”specifier limited to first 4weeks PP.!No specifier for pregnancy!Old myths perpetuateAmy-Rose White LCSW- Copyright 20177
DEPRESSIONIN WOMEN! Leadingcause ofdisease-relateddisability! Reproductiveyears-highest risk! Mostamenable to Tx
Did you know "Women in their childbearing years account forthe largest group of Americans with Depression."Postpartum Depression is the most commoncomplication of childbirth."There are as many new cases of motherssuffering from Maternal Depression each year aswomen diagnosed with breast cancer."American Academy of Pediatrics has noted thatMaternal Depression is the most underdiagnosed obstetric complication in America.Despite the prevalence Maternal Depressiongoes largely undiagnosed and untreated.Amy-Rose White LCSW- Copyright 2017"9
10Maternal MortalitySuicide is the secondleading cause of deathin the first yearpostpartumAmy-Rose White LCSW- Copyright 2017
Perinatal Mood,Anxiety,Obsessive, &Trauma relatedDisordersPregnancy andthe First yearPostpartum#Psychosis- Thought Disorder orEpisode 1-2%# Major21%Depressive Disorder # Bi-PolarDisorder 22% of PPD# Generalized# PanicAnxiety 15%Disorder 11%# ObsessiveCompulsiveDisorder 5-11%# Post Traumatic 9%Stress Disorder
Disparities in prenatalscreening and educationPreterm birth ( 36wk): 11.39%(National Vital Statistics 2013)Low birth weight ( 2500 g): 8.02%(National Vital Statistics 2013)Preeclampsia/eclampsia: 5-8%(Preeclampsia Foundation, 2010)Gestational Diabetes: 7%(NIH, National Diabetes Information Clearinghouse, 2009)Amy-Rose White LCSW- Copyright 201712
13Perinatal MoodDisorders Baby Blues – Not a disorder Major Depressive Disorder- Most researched Bipolar Disorder- Mania high risk for Psychosis- Immediate AssessmentAmy-Rose White LCSW- Copyright 2017
14Baby Blues! 80%! Transient.! Overwhelmed, tearful, exhausted, hypo-manic,irritable! Withsupport, rest, and good nutrition, the BabyBlues resolve naturally.! Persistingbeyond 2 weeks, likely PPD orrelated disorder.Amy-Rose White LCSW- Copyright 2017
15Antenatal DepressionPrevalence10-20%" 14%(JAMA 2013)Amy-Rose White LCSW- Copyright 2017
16JAMA 2013!1 in 7 women PPD!30% episode before pregnancy!40% 1 during pregnancy!Over two-thirds of the women also had signs of ananxiety disorder!One in five of the women had thoughts of harmingthemselves!20 percent of the group studied was diagnosed withbipolar ingstatistics#sthash.CI8AwKFJ.dpufAmy-Rose White LCSW- Copyright 2017
Antenatal DepressionCharacteristics! 60% ! StartsPMADs begin in pregnancy1-3 months postpartum, up to first year! Timing! 60% ! Lastsmay be influenced by weaningPMADs start in first 6 weeksmonths or years, if untreated! Symptoms! Canpresent most of the timeoccur after birth of any child-not just 1st! DSM Vrecognizes episodes in pregnancy and in thefirst 4 weeks PP with “peripartum onset” specifier
DSM V Five or more out of 9 symptoms (including at least one ofdepressed mood and loss of interest or pleasure) in the same 2-week period. Each of thesesymptoms represents a change from previous functioning, and needs to be present nearlyevery day:Depressed mood (subjective orobserved); can be irritablemood in children andadolescents, most of the day;!Impaired concentration orindecisiveness; or!Recurrent thoughts of death orsuicidal ideation or attempt.!Change in weight or appetite.Weight: 5 percent change over 1month;b) Symptoms cause significantdistress or impairment.!c) Episode is not attributable to asubstance or medical condition.!Insomnia or hypersomnia;!!Psychomotor retardation oragitation (observed);d) Episode is not better explainedby a psychotic disorder.!e) There has never been a manic orhypomanic episode. Exclusion e)does not apply if a (hypo)manicepisode was substance-induced orattributable to a medical condition.!!!Loss of interest or pleasure, mostof the day;!Loss of energy or fatigue;!Worthlessness or guilt;
Perinatal DepressionPerinatal Specific! Agitateddepression! Alwaysan anxiouscomponent! Anhedoniausually notregarding infant andchildren! Looks “Toogood”Perinatal Specific! Typicallyhighlyfunctional! HiddenIllness! Intenseshame! Sleepdisturbances! Passive/Activeideationsuicidal
Perinatal DepressionPerinatal Specific! Disinterestin Baby! Inadequacy! Disinterestin sex! Over-concernfor baby! Hopelessness& shame
BIPOLAR DISORDERin Pregnancy7x more likely to be hospitalized for first episode ofPostpartum Depression (Misri, 2005) High relapse rates with continued treatment:45% (Bleharet al., 1998)50% (Freeman et al., 2002) High relapse rates with Lithium treatment discont.:50% (about same as non-pregnant)(Viguera& Newport, 2005)Amy-Rose White LCSW- Copyright 201721
22Bipolar Disorder –Postpartum Psychosis Link! 100xmore likely to have Postpartum Psychosis(Misri, 2005)! 86%of 110 women with Postpartum Psychosissubsequently diagnosed with Bipolar Disorder(Robertson, 2003)! 260episodes of Postpartum Psychosis in 1,000deliveries in women with Bipolar Disorder(Jones & Craddock, 2001)Amy-Rose White LCSW- Copyright 2017
23Perinatal AnxietyDisordersPosttraumatic Stress Disorder(PTSD)Obsessive Compulsive Disorder(OCD)Generalized Anxiety DisorderPanic DisorderAmy-Rose White LCSW- Copyright 2017
24PTSD or Depression? Or both?Amy-Rose White LCSW- Copyright 2017
OCD - General! Obsessions! Intrusivethoughts/ images! Ignore or suppress! Awareness! Compulsions! Repetitivebehaviors/ mental acts! Reduce stress! Prevent dreaded eventAmy-Rose White LCSW- Copyright 201725
Perinatal OCD" Pregnancy: 0.226–1.2%" Postpartum: 2.7–3.9%" (Gen. Pop. 2.2%)" Ego-dystonic obsessionalbaby (Abramowitz et al., 2003)" Nothoughts about harming thedocumented case of infanticide (Ross et al., 2006)" Carefulassessment & close monitoring if :- severe comorbid depression- family or personal history of Bipolar Disorder,Thought Disorders or Postpartum PsychosisAmy-Rose White LCSW- Copyright 2017
27Postpartum OCD(Often misdiagnosed at psychosis)Obsessive thoughts! ContentbabyCompulsive behaviorsrelated to! Motherextremelydistraught! Keep! Ego-dystonic! Repetitive, excessive! “AmI going crazy?”this PostpartumPsychosis?”! “IsI going be thatmother on the news?”! “AmAmy-Rose White LCSW- Copyright 2017baby safe! Reducedistress! Order, control
POSTPARTUM OCDCharacteristics! Nointent to act on thoughts! Motherrarely discloses! Usuallydoes not describe content! Suggestibility! Functioning/! Onlyobsessions or only compulsions or both! Lifelongmild symptoms! Obsession!infant care compromisedwith safety vs harm“But it could happen”Amy-Rose White LCSW- Copyright 201728
29Perinatal Psychosis"Aspart of :"MajorDepressive Disorder"BipolarDisorder –a variant ose White LCSW- Copyright 2017
30Perinatal Psychosis1-3 per thousand births! Agitation! Swiftdetachmentfrom reality! Visualor auditoryhallucinations! Usuallywithin daysto weeks of birthAmy-Rose White LCSW- Copyright 2017! Etiology: Manicphase of Bi-polar I orII! Highrisk! Suicide5%! Infanticide! Immediate4%Hospitalization
31POSTPARTUM OCD vs. PSYCHOSIS"OCD: overprotective mother"PSYCHOSIS: danger to harm"Obsessing about becoming psychoticMyths:"Postpartum OCD is great risk to harm baby"OCD may turn into psychosisIssues:"Misdiagnosis by untrained professionals"Reporting, hospitalization victimizationAmy-Rose White LCSW- Copyright 2017
Other perinatal considerations Although not well researched or included in most dataset, the following populations and reproductive healthevents also experience and represent risk for PMADs.!Same-sex parents!Fathers!Miscarriage (Any length of nAmy-Rose White LCSW- Copyright 201732
33Depression/anxiety duringpregnancy is a strong predictor ofpostpartum mood and anxietydisordersMYTH:Pregnancy protectswomen frompsychologicaldisordersAmy-Rose White LCSW- Copyright 2017
Epigenetic Biomarkers ofPostpartum Depression! Biomarker!loci at HP1BP3 and TTC9BPredicted PPD! Leptin-A fat-derived hormone that signals satiety! Serumleptin level measured 48 h after delivery isassociated with development of postpartumdepressive symptomsNeuropsychopharmacology. 2014 Jan; 39(1): 234. Published online 2013 Dec 9. doi:10.1038/npp.2013.238Chen C, Gao J, Zhang J, Jia L, Yu T, Zheng Y.Serum leptin level measured 48 h after delivery is associated with development ofpostpartum depressive symptoms: a 3-month follow-up study. Arch Womens Ment Health.2016 Jun 13. [Epub ahead of print]
35Etiology of PMADs! Genetic Predisposition! Sensitivity to hormonalchanges! Psychosocial Factors Inadequate social, family,PsychologicalSocialfinancial support! Concurrent Stressors Sleep disruption poor nutrition health challenges Interpersonal stressAmy-Rose White LCSW- Copyright 2017Physical
36Etiology- Current theories! Neuroendocrine! Progesterone! ivation! Stressorscombined with the above HPAaxis dysregulationAmy-Rose White LCSW- Copyright 2017
GLANDS INVOLVED IN MOODREGULATIONAdrenal Gland- Adrenal cortex produces cortisol andheightens arousal, also vital in CNS and metabolic function(helps control insulin release).!!Pituitary Gland- released ACTH which triggers theproduction of cortisolHow does stress effect the thyroid function?!When the adrenal glands become stressed inflammatorycytokines are released which inhibit production of THS, T3,and T4!Enzymes in the gut that normally convert T4 to T3 areinhibited when the body is stressed and result in thyroidresistance
Important R/O38! PTSD! Birthing Trauma! Undisclosed! ACEtrauma or abusequestionnaire! Thyroid/Endocrineimbalance! Anemia! Sideeffects of other medicines! Alcoholor drug use/abuseAmy-Rose White LCSW- Copyright 2017
39Inflammation and PPD: The newetiology paradigm!Psychoneuroimmunology (PNI) new insights!Once seen as one risk factor; now seen as THE risk factorunderlying all others!Depression associated with inflammation manifested by pro-inflammatory cytokines!Cytokines normally increase in third trimester: vulnerability!Explains why stress increases risk!Psychosocial, Behavioral & Physical!Prevention and treatment to maternal stress &inflammation(Kendall-Tackett 2015)Amy-Rose White LCSW- Copyright 2017
40Pro-inflammatory Cytokines!%Third Trimester!%Risk!%Pre-term Birth!%PreeclampsiaAmy-Rose White LCSW- Copyright 2017
41IMPACT OF DEPRESSIONDURING PREGNANCY Prematurity Growth Delays Low birth-weight Difficult temperament Disorganized sleep Impacted development: Less responsiveness Attention Excessive fetal activityAnxiety and depression Chronic illness inadulthood American Academy of ChildAdolescent Psychiatry. 2007 Jun;46(6):737-46.Amy-Rose White LCSW- Copyright 2017
IMPACT OF ANXIETYDURING PREGNANCY" Stress, Anxiety( cortisol) Maternal vasoconstriction Decreased oxygen and nutrients to fetus(Copper et al., 1996)" Consequenceson fetal CNS development(Monk et al., 2000; Wadhwaet al., 1993)" Pre-termdelivery ( 37wks)(Kendall-Tackett 2015; Dayan et al., 2006; Hedegaardet al., 1993; Riniet al.,1999; Sandman et al., 1994; Wadhwaet al., 1993)Amy-Rose White LCSW- Copyright 201742
IMPACT OF POSTPARTUMDEPRESSION:Infant Development" Poorinfant development at 2 months(Whiffen& Gotlib, 1989)" Lowerinfant social and performance scores at 3 months(Galleret al., 2000)" Delayedmotor development at 6 months(Galleret al., 2000)" Morelikely to have insecure attachment styles(Martins & Gaffan, 2000)Amy-Rose White LCSW- Copyright 201743
44Etiology of fetal impact hypothesis:Potential Mediating variables:! Lowprenatal maternal dopamine and serotonin! Elevatedcortisol and norepinephrine! Intrauterineartery resistance! Heritability– ADHD, anti-social behaviorAmy-Rose White LCSW- Copyright 2017
IMPACT OF POSTPARTUMDEPRESSION: Older ChildrenChildren exposed to maternal depression as infants:"More conduct problems(Beck C.T., 1999: Meta-analysis of 33 studies)"Lower perceptual performance scores at age 4(Brennan et al., 2000)"More behavior problems and lower vocabulary scores at age 5(Brennan et al., 2000)"More likely to express negative cognitions of hopelessness, pessimismand low self-worth at age 5(Murray, Woolgar, Cooper, & Hipwell, 2001)"Lower levels of social competence at ages 8-9Amy-Rose White LCSW- Copyright 201745
IMPACT OFPOSTPARTUM DEPRESSION cont.!More frequent non-routine pediatrician visits (Cheet al.,2008)!Current depression is associated with larger effect than pastdepression!Infants of depressed mothers experience more impairedparenting than older children of depressed mothers!Economically disadvantaged mothers experience negativeeffects of their depression to a greater extent (Lovejoy et al.,2000)!Significantly more likely to discontinue breastfeedingbetween 4 and 16 weeks postpartum. ( Field 2008) (Ystrom2012)!PPD and low support leads to early weaning Mathews et alJHL 30(4) 480-487Amy-Rose White LCSW- Copyright 201746
47Protective benefits ofbreastfeeding! Attenuatesstress! Modulatesinflammatory response! Protectiveaffect on the neural development ofinfantsDennis & McQueen, (2009), Hale (2007)Kendall-Tackett, Cogig & Hale, (2010)Kendall-Tackett (2015)Amy-Rose White LCSW- Copyright 2017
48Potential negative impact ofnursing on depressed mothers! PNIresearch suggests that the naturalinflammatory response on pregnancy, combinedwith inflammatory process such as stress and pain,i.e.: nipple pain, can increase risk and severity ofsymptoms.! Whennursing is going well protective.! Whennursing is very stressful and/or painful increased risk.Kendall-Tackett (2015)Amy-Rose White LCSW- Copyright 2017
PREVENTION –Primary Prevention Model! Riskfactors are known! Screening! Riskis inexpensivefactors for PMADs are well-documented! Manyrisk factors amenable to change! Someare genetic, others are psychosocial and thus can beimpacted with primary prevention strategies! Known, reliable, effectivetreatments exist
PREVENTIONAll women need:! Information! Exercise! Rest! Soundnutrition! Socialsupport
PREVENTIONResearch! Mixedresults examining interpersonal therapy, groupsupport, home visits! Prophylacticpsychopharmacology-! PPDprevented with use of Sertraline immediatelypostpartum for 24 women w/history of PPD.! Initialdose 25mg, Maximum dose 75mg
PREVENTIONGlobal GoalsGlobal goals for prevention and treatment! Reducematernal stress! Reduceinflammation! Belowsupport/treatment strategies generallyconsidered anti-inflammatory
53Universal Primary Prevention inpractice! Educate “If! Screen! Referyou’re not feeling like yourself”- EPDS or PDQ 9– www.utahmmhc.org! Provideinfo/resources – UMMHC Brochure! Wellnessplanning - SNOWBALLAmy-Rose White LCSW- Copyright 2017
Identifying riskAmy-Rose White LCSW- Copyright 201754
Antenatal Depression Risk!All cultures and SES!First year postpartum!Higher rates:-Multiples-Infertility-Hx Miscarriage-Preterm infants-Teens-Substance abuse-Domestic Violence-Neonatal complicationsAmy-Rose White LCSW- Copyright 201755
Trauma Hx and risk!Statistically significant link between childhood sexual abuseand antenatal depression!Atenatal depression predicted by trauma Hx – dose-responseeffect.! 3 traumatic events 4 fold increased risk vs. no T hx!Long-term alterations in concentrations of corticotropinreleasing hormone (CRH) and cortisol!Dysregulation of the HPA axis neuroendocrine changes ofpregnancy!Increasing levels of CRH !ACES Questionnaire significantMoodWosu AC, Gelaye B, Williams MA.History of childhood sexual abuse and risk of prenatal and postpartum depression or depressivesymptoms: an epidemiologic review. Arch Womens Ment Health. 2015 May 10.Robertson-Blackmore E, Putnam FW, Rubinow DR, et al.Antecedent trauma exposure and risk of depression in the perinatal period. J Clin Psychiatry. 2013 Oct;74(10):e942-8.
57Predictive Risk Factors! PreviousPMADs! Family History! Personal History! Symptoms during! HistoryPregnancyof Mood or Anxiety Disorders! Personalor family history of depression, anxiety,bipolar disorder, eating disorders, or OCD! SignificantchangesMood Reactions to hormonal! Puberty, PMS,lossAmy-Rose White LCSW- Copyright 2017hormonal birth control, pregnancy
58Risk Factors cont.!Endocrine Dysfunction!!!!Hx of Thyroid ImbalanceOther Endocrine DisordersDecreased FertilitySocial Factors!!!Inadequate social supportInterpersonal ViolenceFinancial Stress/PovertyAmy-Rose White LCSW- Copyright 2017
59NICU Families! PTSD! nopreterm delivery 7.4%ptsd 8%! withpast ptsd 9.2%! withcurrent ptsd 16,334 VA deliveries! PTSDand major depressive disorder is 4fold increase in prematurity 2654 womenAmy-Rose White LCSW- Copyright 2017
Risk Factor Check ListFrom Oregon Prenatal and Newborn Handbook 2015Check the statements that are true for you:#It’s hard for me to ask for help.I’ve had trouble with hormones and moods, especially before myperiod.##I was depressed or anxious after my last baby or during my pregnancy.#I’ve been depressed or anxious in the past.#My mother, sister, or aunt was depressed after her baby was born.Sometimes I don’t need to sleep, have lots of ideas and it’s hard toslow down.##My family is far away and I don’t have many friends nearby.#I don’t have the money, food or housing I need.If you checked three or more boxes, you are more likely to have depressionor anxiety after your baby is born (postpartum depression).Amy-Rose White LCSW- Copyright 201760
61SCREENING –What tool?! EdinburghPostnatal Depression Scale (EPDS)(Cox, Holden & Sagovsky, 1987)! 10item self-screen! Pre & postnatal use! Copyright-free! Not a diagnostic tool! Not to override clinical assessment! Available in 23 languages! PostpartumDepression Screening Scale (PDSS)(Beck & Gable, 2000)! PatientHealth Questionnaire (PHQ-9)Amy-Rose White LCSW- Copyright 2017
62Screening: When?EveryPrenatal VisitAmy-Rose White LCSW- Copyright 2017EPDS senthome withmomEvery wellbaby checkfor the firstyear
63SCREENING –How?"Do not make assumptions"Educate"Ask every woman: “At least 10% of pregnant and postpartumwomen have depression and or anxiety. They are the mostcommon complications of childbearing.”"More than once"Give screening tool with other paperwork"Ask about personal and family history of depression &anxiety"Document"Give printed resources with phone numbers and websitesAmy-Rose White LCSW- Copyright 2017
64Treatment: The Gold Standard:Amy-Rose White LCSW- Copyright 2017
65BEHAVIORAL &SOCIAL SUPPORT TREATMENTPsychotherapy:Crisis interventionIPT, CBT, MCBT, DBTIndividual, couples, familySupport groupsPhone/ email supportAmy-Rose White LCSW- Copyright 2017
HOSPITALIZATION! Whensafety/functioning level warrant! Outpatient! Multipleinpatient! Alwayscarefactors should be considered whileneeded for psychosis and activesuicidality
Treatment Options for Perinatal Patientswith moderate-severe sx!Ideal –specialized out-pt and in-pt optionsMother-baby day tx offers high-profile tx whilepromoting attachment and the infant/motherrelationship.!!Lowers impact of trauma of PPD!Assures safetyContextualized tx much more appealing to newmoms!
Hospital-based preventionprograms! 16states currently offer hospital-based preventionand treatment programs for PMADs! Screeningall PP women! Follow-upphone calls! Referralsto MDs! In-hospitalsupport groups
Canada: Mt. Sinai HospitalPerinatal Mental Health Program! Toronto!5day 5 night program for high-risk moms! Hxof PPD, or Bi-polar! Emphasis! Basedon monitoring and sleepon clear link between fatigue, sleepdeprivation and sx worsening/mania.
BEHAVIORAL &SOCIAL SUPPORT TREATMENTIPT, CBT, DBTMBCTSupport groupsECTPhone/email supportShort term CBT as effective asFluoxetine
Social Support: Prevention &Intervention!New Canadian research!9 phone call model!RN supervised peersupport trainingprogram!RN’s providedDebriefing and clinicalassessment re: suicidality!Mean depression significantlydeclined from baseline, 15·4(N 49), to mid-point, 8·30 andend of the study, 6·26.!At mid-point 8·1% (n 3/37) ofmothers were depressed!At endpoint 11·8% (4/34) weredepressed suggesting somerelapse.!Perceptions of social supportsignificantly improved andhigher support wassignificantly related with lowerdepression symptoms.
MEDICATION! PrescribedbyPsychiatrist! Primary Care Physician! Psychiatric Nurse Practitioner! OB!! Potential! Ofteneffects weighed while pregnant or nursinga process! Multipletypes of PMAD medications! Adjunctivelorazapamuse of benzodiazepines clonazepam,
Non-Pharmacological Tx" Mindfulness" OmegaCBT3s" 5-HTP" Acupuncture" Hypnotherapy" DoulaCare" Meditation" Brightlight" Herbs" Yoga" Massage" SAM-E" Homeopathy" St. Johns Wort" PlacentalEncapsulation?
OMEGA 3 FATTY ACIDS!Safe for pregnancy and nursing!Proven effective for depression and bipolar disorder!Supports proper brain function and mood!Omega 3s related to mood found mostly in fish oil!EPA & DHA!Combined therapeutic dosage: 1,000-3,000 mg (up to 9000)!Must be high quality supplement source(Kendall-Tackett, 2008)
Rule outs &Tx resistant considerations ThyroidNutritional deficiencies (Omega 3-s, B-12,Iodine, ferritin, magnesium, calcium)Glucose intoleranceOther biological causesFood allergiesSerotonin imbalance (amino acids, 5-HTP)Endocrine/Hormone imbalance (Progesterone,Estrogen, Testosterone)
PHARMACOLOGICALTREATMENT OPTIONS! SSRIs! Anti-anxiety! Moodagentsstabilizers! Anti-psychoticagents“I have spent the last 10 years of my career worrying aboutthe impact of medications. I’ve been wrong. I should havebeen worrying more about the impact of illness.”-Zachary Stowe, MD. Department of Psychiatry, Emory University2007Amy-Rose White LCSW- Copyright 201776
77!Forinformation on medication whilebreastfeeding, call Pregnancy RiskLine: Mother-to-BabySalt Lake: 1-800-822-BABY (2229)Amy-Rose White LCSW- Copyright 2017
PSYCHOTROPIC MEDICATIONS INPREGNANCY & LACTATIONWhy Many Women Don’t Seek Treatment!Afraid they will be told to stop breastfeeding!!Most women know that breastfeeding is best for their infantRather “get through it” than give up nursing!Afraid of impact on neonate!Stigma!Are not given:!!!Adequate information about risks/ benefitsChance to discuss it with othersAuthority to make final decisionAmy-Rose White LCSW- Copyright 201778
79CULTURAL CONSIDERATIONS Language Barrier PSI website www.postpartum.nettranslatable EPDS available in 22 languages “Beyond the Blues” in Spanish “Healthy Moms, Happy Families”video- PSI. www.postpartum.netOther barriersLocal community resourcesAmy-Rose White LCSW- Copyright 2017
Prevention & Tx:CONCRETE STRATEGIES
Prevention & TreatmentWellness Planning! Sleep! Nutrition! Omega-3s! Walk! Babybreaks! Adulttime! Liquids! LaughterAmy-Rose White LCSW- Copyright 2017See www.utahmmhc.org81
82Treatment Options for Perinatal Patients athigh risk for suicide!Ideal –specialized out-pt and in-pt optionsMother-baby day tx offers high-profile tx whilepromoting attachment and the infant/motherrelationship.!!Lowers impact of trauma of PPD!Assures safetyContextualized tx much more appealing to newmoms!!St. Marks Perinatal IOP: (801) 268-7438Amy-Rose White LCSW- Copyright 2017
83Screening: EPDS!Edinburgh Question #10: “The thought of harming myselfhas occurred to me.”!If she answers with anything other than 0, the provider mustfollow up to address threat of harm!Ask questions, clarify - “Thoughts of self-harm are prettycommon”!Frequency, intensity, ithm.pdf!Immediate Perinatal Mental Health Assessment!Do not avoid questions that are uncomfortableAmy-Rose White LCSW- Copyright 2017
84Stanley Safety Plan Template! ploads/2016/08/Brown StanleySafetyPlanTemplate.pdf! https://suicidepreventionlifeline.org! 1-800-273-8255Amy-Rose White LCSW- Copyright 2017
al Hopeline Network1-800-784-2433 (800-SUICIDE)www.hopeline.com/National Suicide Prevention Lifeline1-800-273-8255Amy-Rose White LCSW- Copyright 2017
86Best options in Utah! NearestER! 911! UNI! Giveoptions! Know! Let! SLC:limits of rolego of outcomeAmy-Rose White LCSW- Copyright 2017Mobile CrisisTeam! Assessment! (801)in home587-3000
87No imminent danger- high risk!!!Ideally makes a safety planfor 24 hr care while waitingfor an assessment with aspecialist!Utilize PSI coordinators listfor safety planning andfollow up!See www.utahmmhc.comHelp Me Grow 22!1-800-PPD-MOMSPlan to check back in within 24-48 hrs!Encourage checking inspanel and UMMHC websiteas well as PSIAmy-Rose White LCSW- Copyright 2017
Psychiatric Hospitalization:Key Considerations!R/o psychosis!Consider pt demographics!Undiagnosed Bi-Polar!Breast pump available!OCD vs Psychosis!Lactation support!PPD vs. PTSD!Support choices!Pts that look “too good”!Baby visits!Careful suicide screening!SLEEP!Prescriber ed re: pregnancy andlactation!Careful d/c planning!Specialized referrals!Support for familyAmy-Rose White LCSW- Copyright 201788
In PatientHospitalizationKey considerations!89! Carefulcase coordination! D/cplanning! F/uappointment made! Linkedgroupsup with local support! PSIcoordinator! Listof resources, websitesetc.! Wellness! Givenplan in writingto family etc.! ConcretestrategiesAmy-Rose White LCSW- Copyright 2017
90Provider Resources"www.mededppd.com – CDC sponsored site for providersand families. Excellent current research and free Ces."www.womensmentalhealth.org MGH Center for Women’sMental Health: Reproductive Psychiatry Resource andInformation Center. Harvard Medical School."www.motherisk.org Medication safety and resources."(800-944-4773) -Postpartum Support International. Largestperinatal volunteer organization with free phone support/groups in every state and most developed countries.www.postpartum.net"St Marks Perinatal IOP - (801) 268-7438Amy-Rose White LCSW- Copyright 2017
91PMAD resources!www.utahmmhc.com - Utah Maternal Mental HealthCollaborative. Interagency networking, resource and policydevelopment. See website for many resources, free supportgroups, etc.!www.postpartum.net - Postpartum Support International.2020mom partner and largest perinatal support organization.Resources and training for providers and families. Freesupport groups, phone, and email support in every state andmost countries.!http://www.mmhcoalition.com -National Coalition forMaternal Mental Health- Social Media Awareness Campaign,ACOG, private & non-profit.Amy-Rose White LCSW- Copyright 2017
92 !Whatwill YOU do in yourscope of practice to increasedetection and treatment?Amy-Rose White LCSW- Copyright 2017
Additional ResourcesThe following slides are for additionalinformation for help and support
PSI Support for Families PSI Support Coordinator Networkwww.postpartum.net/Get-Help.aspx! Every state and more than 40 countries! Specialized Support: military, dads, legal,psychosis! PSI Facebook Group Toll-free Helpline 800-944-4PPD support towomen and families in English & Spanish Free Telephone Chat with an ExpertAmy-Rose White LCSW- Copyright 201794
95PSI Chat with an Expert! t.aspx! Every Wednesday! Firstfor MomsMondays for Dads! NewChats in development! Spanish-speaking! Lesbian MomsAmy-Rose White LCSW- Copyright 2017
96PSI r.aspx!Discounts on trainings and products!Professional and Volunteer training and connection!PSI Chapter development!Members-only section of website!!!!List your practice or group, find othersConference PresentationsWorldwide networkingProfessional Membership Listserves!PSI Care Providers; International Repro Psych Group!Special student membership discount!Serve on PSI CommitteesAmy-Rose White LCSW- Copyright 2017
PSI Public Awareness Posters“You are not s-Poster-.aspxAmy-Rose White LCSW- Copyright 2017
PSI Educational Brochures98English & spxAmy-Rose White LCSW- Copyright 2017
PSI Educational DVDs99Healthy Mom, Happy Family13 minute DVDInformation, Real Stories, Hope1-800-944-4773www.postpartum.ne
Perinatal Mood, Anxiety, Obsessive, & Trauma related Disorders # Psychosis- Thought Disorder or Episode 1-2% # Major Depressive Disorder 21% # Bi-Polar Disorder 22% of PPD # Generalized Anxiety 15% # Panic Disorder 11% # Obsessive Compulsive Disorder 5-11% # Post Traumatic Stress Disorder 9% Pregnancy and the First year .
PSI AP Physics 1 Name_ Multiple Choice 1. Two&sound&sources&S 1∧&S p;Hz&and250&Hz.&Whenwe& esult&is:& (A) great&&&&&(C)&The&same&&&&&
Perinatal anxiety or perinatal OCD – some people develop anxiety problems during pregnancy or in the first year after giving birth. See our resource on perinatal anxiety and perinatal OCD for more information. "It's like a swarm of bees just buzzing buzzing buzzing, not
Anxiety disorders affect 8‐10% of adolescents Most anxiety disorders begin in childhood and adolescent years. Anxiety disorders are hereditary Many individuals with anxiety disorders experience physical symptoms and present to their family physician or health care provider.
Perinatal Mood & Anxiety Disorders Consultation Service Provides consultation and education for healthcare, mental health, and community providers . Unrelated to past mental health or psychosocial stressors May last a few hours to 14 days Responds to supportive interventions Still future oriented, worries are not unmanageable, .
The rubric of "affective disorder," which in some European classifications also subsumes morbid anxiety states, is increasingly being replaced by . Boundaries The boundaries between temperament (personality) and mood disorder, grief and melancholia, anxiety and depressive states, depressive and bipolar disorders, mood-congruent and .
Argilla Almond&David Arrivederci&ragazzi Malle&L. Artemis&Fowl ColferD. Ascoltail&mio&cuore Pitzorno&B. ASSASSINATION Sgardoli&G. Auschwitzero&il&numero&220545 AveyD. di&mare Salgari&E. Avventurain&Egitto Pederiali&G. Avventure&di&storie AA.&VV. Baby&sitter&blues Murail&Marie]Aude Bambini&di&farina FineAnna
her community" (World Health Organization) Mental health: not the same as absence of mental illness, reflects a capacity to adapt and cope Perinatal mood and anxiety disorder (PMAD): A term that encompasses disorders occurring during pregnancy and the first year after a woman gives birth. Prenatal and postpartum can
with API 650’s level of risk of tank failure. Likewise, the rules in the external pressure appendix will be consistent with the basic part of API 650 with regard to loading conditions and combinations. Thus, starting with a specified design external pressure, roof live or snow load, and wind pressure (or velocity), the total roof design pressure is calculated as the greater of DL (Lr or S .
