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Perinatal Mood Disorders

A Guide for Health Care Providers

The goal of this resource is to provide information for primary health care providers on routine screening, assessment and treatment of perinatal mood disorders (PMD). PMD is now the most common complication of childbearing, yet many women go undiagnosed and untreated.

Untreated mood disorders can increase preterm birth, increase breastfeeding difficulties, cause strain on the family and negatively impact secure infant attachment and child development. Early detection through screening is an important first step.

Background

Perinatal Mood Disorders (PMD) are a collection of mental illnesses that occur during pregnancy, after the birth of a baby, after a still birth or miscarriage; or even after an adoption. Symptoms can appear in pregnancy or anytime in the first year after birth. The most prevalent disorders are Depression and Anxiety. Other less common PMDs include: Obsessive-Compulsive Disorder, Mania, Panic Disorder, Post-Traumatic Stress and Postpartum Psychosis. Postpartum Psychosis, the most severe disorder, is rare.

Facts

  • Young couple holding baby10-20% of women are affected to varying degrees by a PMD, but this is probably underestimated as many women “suffer in silence”
  • About 50% of women with a previous history of depression will experience maternal depression
  • 30% of women diagnosed with postpartum depression had their initial onset of depression during pregnancy
  • Women who are known to have experienced an episode of postpartum depression have up to a 40% risk of experiencing another postpartum depression
  • Teen moms and new immigrants both have a higher incidence of PMD
  • Approximately 10% of men will experience Paternal Postpartum Depression (PPD) and this incidence is much higher if their partners also have PMD

PMD constitutes a major public health problem affecting women, their partners and families and the children they care for. As a result, it is important to focus on increasing awareness, early identification, diagnosis and treatment of these disorders.

Signs and Symptoms

Up to 80% of postpartum women will experience “the blues” in the first few days after giving birth. The baby blues are considered to be part of the normal postpartum adjustment period and may include: sadness; crying spells; poor concentration; irritability; feeling exhausted and overwhelmed. The symptoms are usually mild, transient and time limited, and do not require treatment, other than reassurance. If symptoms persist beyond 14 days, this indicates a need for further assessment. Up to 20% of women with the blues develop major depression within the first year of having a baby.

Perinatal Mood Disorders (PMD)

  • Affect up to 10% of pregnant women, up to 20% of postpartum women and 10% of new dads
  • May include Depression, Anxiety, Obsessive-Compulsive Disorder, Mania, and Post-Traumatic Stress Disorder
  • Due to stigma, some women may report physical symptoms (e.g. headache, backache, stomach ache, tightness in chest, shortness of breath) instead of expressing feelings

Symptoms may include feeling:

  • Sad and tearful
  • Overwhelmed
  • Exhausted, but unable to sleep
  • Restless, irritable or angry
  • Anxious or worried
  • Hopeless or frustrated
  • Guilty and ashamed
  • Panicky
  • Fearful of "going crazy"
  • Like a failure
  • Hyper vigilant around the baby

Having difficulty:

  • Sleeping
  • Eating
  • Relaxing
  • Concentrating
  • Remembering things
  • Bonding with the baby
  • Feeling socially connected

Having thoughts of:

  • Harming self*
  • Harming baby*
  • Harming others*

*require further assessment and may require immediate referral to crisis services

Postpartum Psychosis

  • Affects 1 or 2 postpartum women in 1000
  • Most severe and least common postpartum mood disorder
  • Onset is sudden and usually occurs within the first 2-3 weeks
  • Can last for weeks to months and usually requires hospitalization

Psychotic symptoms may include:

  • Thinking and possibly planning to harm self , baby or someone else
  • Hearing or seeing things that are not there (hallucinations, voices)
  • Believing people are going to harm her or the baby (paranoia)
  • Feeling confused and out of touch with reality (includes delusions)

This is a medical emergency and requires immediate hospitalization.

Risk Factors

Although women of all ethnic, economic and education backgrounds can develop Perinatal Mood Disorders (PMD), some women are more at risk.

Risk factors in descending order of significance include:

  • Previous history of Anxiety, Depression or PMD
  • Family history of Depression
  • Recent stressful life eventsMother consoling daughter
  • Lack of social support
  • Relationship difficulties
  • Being a teen mom
  • Being a new immigrant
  • An anxious personality
  • Pregnancy and/or obstetric complications

Screening and Assessment

Universal screening of all pregnant and postpartum women is a quick and easy way to determine women at risk as well as helping to reduce stigma of mental health problems.

Barriers to Detection

It can sometimes be difficult to distinguish between the signs and symptoms of a Perinatal Mood Disorder (PMD) and normal perinatal adjustment. Symptoms may be attributed to hormone changes, lack of sleep or demands of the baby.

Many women may be reluctant to disclose their symptoms due to guilt and shame. Cultural or religious reasons may also prevent disclosure. As such, detecting PMD in women can be challenging.

The stigma for men disclosing depressive symptoms is even greater. If a woman has PMD it is good practice to inquire about the father’s coping as well. Men usually present with different symptoms- often anger, impulsivity and irritability. Some turn to substances or avoidance, retreating into work or other activities. These behaviours may not be picked up on by others so the dads may fall through the cracks. Untreated, the effects of Paternal Postpartum Depression (PPD) can be long lasting and detrimental to the relationship, to child development, and to the overall well-being of the father.

Listening to your patients, validating their feelings, using open-ended questions and speaking in a calm, non- judgmental manner can help overcome these barriers. It is important to assess all patients in the perinatal period as they may look well but may not be coping.

Initial Assessment Questions:

The following four questions can be used to ask about the emotional well-being of all new mothers and can be easily incorporated into everyday clinical practice. (adapted with permission from PASS-CAN) They can be asked on every prenatal visit and on postpartum visits up to one year.

  • Are you able to sleep?

This question will help identify mothers who sleep too much or cannot sleep at all, due to constant worrying and racing thoughts. Drastic changes in sleep pattern can be an indicator of possible PMD. Don’t assume that sleeping is a problem because of a crying baby. Find out what the mother does when the baby is sleeping.

  • Are you getting out?

This question will pick up symptoms of anxiety, depression, agoraphobia, exhaustion and the inability to cope. Women experiencing PMD will often hide their symptoms and will often isolate themselves to keep their symptoms secret. Find out if they are socializing.

  • Are you eating and if so, what are you eating?

This question will pick up symptoms of anxiety, i.e. a mom feels like she has a rock in her stomach or something constricting her throat, she has no appetite or is over-eating, especially carbohydrates. Find out if this began before or after the baby’s birth.

  • Are you having scary and/or repetitive thoughts?

Mothers sometimes have intrusive thoughts about their baby and/or themselves. Asking this question may open lines of communication, but do not expect that a mother will confide in you at this point. She may be afraid that her baby will be taken away by child protective services. Reassurance that other new parents also have scary thoughts can be helpful. Providing a parent with a safe environment to express her feelings and fears is of utmost importance.

*If concerns arise from the patient’s answers she can be given an Edinburgh Scale to self-complete.

Edinburgh Postnatal Depression Scale (EPDS)

The EPDS is a validated 10 question tool used to assist health care professionals in screening women for Perinatal Depression. Questions 3, 4 and 5 are related to anxiety. (score >4 on these 3 questions may indicate anxiety and requires further assessment).The EPDS may be used anytime during the prenatal period and anytime up to one year postpartum. The EPDS has been translated into 23 different languages. It has also been validated for use with new fathers. Suggested screening times are: 1st prenatal visit and at 28-34 weeks gestation and at 2-3 weeks, 2-4 months and 6 months postpartum or as deemed necessary.

To order free copies of the EPDS, call Durham Health Connection Line 905-666-6241 or 1-800-841-2729

Suggestions for Further Assessment

  • Do you or anyone in your family have a history of depression, anxiety or other psychiatric disorder?
  • Tell me about your support system (partner/family/friends/other)Couple talking to doctor
  • Tell me about any other stressors in your life (i.e., relationship or financial difficulties)
  • In your culture, what does a woman do if she has serious emotional problems?
  • How do you feel about your connection and comfort level with your baby?
  • Do you think you are feeling or reacting differently than other new moms?
  • How is your current mood different from your usual self?

*The Antenatal Psychosocial Health Assessment (ALPHA) is a useful prenatal tool that can identify women who would benefit from additional support and interventions, including mental health support.

Treatment

  • 70 to 80% of affected women are successfully treated and recover
  • Prompt treatment lessens recovery time, prevents harmful consequences for both mother and child, and decreases the probability of relapse
  • Treatment for PMD is similar to treatment for anxiety and depression that occurs at any other time in a woman’s life
  • Most women experiencing PMD respond well to psychotherapy, increased social and practical support and utilizing self-care strategies, but some may require medication as well
  • Treatment is most effective when a personalized plan is developed to meet the needs of the individual woman
  • The plan may involve choosing a single area of deficit and highlighting one goal for each day - this could be as simple as walking around the block or showering each morning
  • Even small victories and accomplishments can lift a patient's mood

Regardless of PMD severity, the following is recommended for all treatment plans:

  • Validation of the woman’s experience
  • Reinforcement that PMD is a real illness that requires treatment, and it is not her “fault”
  • Education for the patient as well as for her partner and family
  • Encouragement of partner/family involvement and support
  • Promotion of self-care strategies

Treatment Options

Medication

  • There is good evidence supporting the use of medication in the treatment of depression and anxiety in general
  • Many women are reluctant to take medication for various reasons (i.e., pregnancy, breastfeeding)
  • The decision on whether or not to use medication, and what type, should be made by each individual woman and her physician, based on the risks and benefits to her and her baby
  • Motherisk is a helpful resource for choosing appropriate medication

Psychotherapy

  • Formal psychotherapy, such as Cognitive Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) may be as effective as antidepressants for some women experiencing mild to moderate depression
  • Supportive care can be offered by all family physicians through the strength of the patient-physician relationship, and through providing compassionate support and information, in a safe, non-judgmental, confidential space

Psychosocial Care

  • Peer or professionally led support groups allow new moms to identify with other women who share the same feelings and normalize their experiences
  • Supportive involvement of partner and family can reduce severity and recovery time
  • Support people can help with meals, chores and infant care and provide emotional comfort
  • Self-care strategies can be promoted as adjuncts to appropriate medical and/or psychological treatment
  • Suggestions include daily exercise, rest, healthy eating, yoga, massage, meditation, deep breathing, light therapy

Durham Region Perinatal Mood Disorders (PMD) Resources

Resources For Patients:

Community Resources:

Patients in Crisis

* Any woman experiencing a mental health crisis, e.g. psychosis, suicidal ideation, or thoughts of harming the baby or someone else, can be assessed by a crisis team at her local hospital emergency department. The patient should be informed that she will be seen by a medical doctor in the E.R. first and then be assessed by the crisis team, so she could be there for several hours. A treatment plan will be developed and any necessary follow up arranged.

For more information on the crisis teams call:

  • Lakeridge Health - 905-576-8711 Ext. 4384
  • Rouge Valley, Ajax Pickering - 905-683-2320 Ext. 3523

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