Perinatal Mood Disorders (Zechowy, 8/28/2024)

Many thanks to Dr. Jill Zechowy for an excellent presentation this week on Perinatal Mood Disorders. A link to the recording is available HERE. 

My notes:

• PPD: perinatal/post partum depression
• PPA: perinatal/post partum anxiety
• PMADs: perinatal mood disorders (including depression, bipolar, anxiety including panic, OCD, GAD)

PPD is persistent low mood lasting >2 weeks, occurring in pregnancy or in first year postpartum, dx'd the same as other forms of depression with the SIGECAPS pneumonic:

• Sleep
• Reduced Interest
• Guilt
• Low Energy
• Impaired Concentration (may be criteria for extending disability)
• Appetite (crave carbs, have low appetite)
• Psychomotor agitation or slowing
• Suicidality

In the first YEAR of life, maternal mental health diagnoses are the number 1 cause of maternal mortality (death from suicidality and/or drug overdose)

PPD differs from major depression in a few ways: more anxiety, changed sleep/lifestyle, parenting responsibilities

Costs for moms/women: PPD affects 1/7 women, PMADs in 1/5 women, 1/10 partners/adoptive parents (roughly 1 million people/year). Depression impairs women's ability to bond with baby, delays/impairs attachment. Depressed moms are less responsive to their babies -- children born to women with untreated PPD are more likely to have externalized behaviors (e.g. conduct issues, fights in school, shouting, hitting, aggressive behaviors). PMADs major cause of divorce, suicide.

Costs to infant: if a person with a uterus is pregnant with depression, more likely to have pre-term birth, SGA, impaired brain growth, developmental delay, behavioral disorders, attachment disorders. Untreated PPD is an ACE for the child.

Who is at risk? People with prior history of depression/anxiety is at increased risk, family history depression/anxiety (even  in a male relative) increases risk of PPD. Trouble sleeping in pregnancy has the strongest correlation with PPD in perinatal time. 

PPD is caused, in part, by hormone changes (e.g. allopregnanolone levels plummet at birth, women with a genetic issue with pregnanolone receptors have severe PPD). But hormones are only part of the explanation. There are other biological issues. Right now, our awareness of mental health of children is so acute that it is a particularly difficult time to mother/parent. The demands of parenting are also an extreme stress.

Screening

All pregnant people should be screened for PPD, positive Edinburgh screening is 9-12 (out of total 30). ACOG recommends in first trimester, again at "later trimester" and every postpartum visit. AAP recommends "mothers be screened for PPD at 1, 2, 4 and 6 month visits". 

• Assess for suicidality: pay particular attention to the suicide question on your screening tool.
• Ask how women are sleeping.
• Screen for bipolar disorder: history of bipolar disorder, family with bpd, ever a time they were agitated/impulsive/didn't sleep/more sexual
• bipolar disorder most often diagnosed postpartum
• Look for evidence of psychosis

Intrusive thoughts vs. Postpartum psychosis

Intrusive thoughts are common in perinatal period (common in PPA, OCD flare). Intrusive thoughts are scary, harsh images of harm coming to the baby (e.g. tripping on baby, imagining pot of hot water burning the baby). These intrusive thoughts make women scared of holding the baby. These get better with time away from baby, more sleep, more support, or OCD/anxiety is treated. They are NOT at risk of harming their baby because the idea is abhorrent.

In psychosis, it is more ego-syntonic. It feels okay, comfortable. People hear voices to kill their baby. This is VERY different. Women with psychosis have very high risk of infanticide (1/1000 risk of killing baby). They need urgent assessment and should not be left alone with their baby. Need ER assist. There is a mother-baby unit in Stanford. 

Principles of treatment

Therapy, medications are both first line. Medication may be more accessible in resource-poor settings.

Also, try not to allow breastfeeding to impair sleep: 5 hours in a row is better than 8 hours with three interruptions due to 3 REM cycles in a row, which is more replenishing for our brain biochemistry.

Don't be shaming when talking about breastfeeding. If a bottle of formula (or pumped milk) allows mom to get 5 hours of sleep, no shame and no blame. Can use power pumping, which is better than pumping in the middle of the night (don't set your alarm q3 hours to pump in the middle of the night).

Medication prescribing: weigh risks of treating vs. risk of untreated depression.

Don't change medication just because a woman is pregnant. 

Don't treat someone halfway (e.g. the lowest dose, but not effective dose, increase sertraline from 25 mg (too low) to more effective/therapeutic dose). When you do this, you are exposing infant to both the medication AND the depression.

Sertraline (Zoloft) has the most safety data, but that doesn't mean it's the safest medication. There isn't enough data to know which SSRI is safer. Sertraline does work for a wide range of diagnoses, so if a woman isn't on medication, sertraline is a good first start. BUT if a person has tried multiple anti-depressants, it's okay to continue that medication; don't switch to sertraline, especially if it didn't work for them in the past.

Perinatal psychiatrists use Reprotox.net (has every study on any medication in pregnancy) or MothertoBaby.org (patient handouts Eng/Spanish)

5 Risks of SSRI:

• poor neonatal adaptation (akin to SSRI withdrawal), occasionally NICU for monitoring and blood sugar
• pulmonary hypertension of newborn: very low risk
• cardiac defects ?some studies show yes, others no (cardiac side effects documented in paroxetine, fluoxetine (rx'd often for PMDD)
• bipolar disorder: do not want to precipitate mania, consider quetiapine QHS for someone who have postpartum bipolar disorder. Get psychiatrist help
• suicidality (always recheck 2 weeks after starting SSRI). Agitation can happen without warning, can be result of agitation that an SSRI can cause, unknown element of BPD. National Suicide Hotline 9-8-8. If they have thoughts of hurting themselves, should stop the med and let you know. 

For Insomnia/Post Partum Anxiety: can use very very very low doses of quetiapine (1/4-1//8 of a 25mg tablet of quetiapine): undetectable in breastmilk. May be safer than sleeping meds (less likely to roll over baby). Consider as adjunct for anxious patients who do not meet criteria for mania but for whom you are worried about starting sertraline. 

The newest treatment option for PPD is Zuranolone: synthetic analog of allopregnanolone. Works very quickly (within 3 days). Only 2 week course (14 pills), Can be done on top of SSRI, anti-psychotic, lithium. Causes profound sedation (no driving). No safety information in breastmilk. Very costly: $1000+/pill, $15,000 for a course. 

Preventing PPD

With specific techniques, up to 50% of PPD can be prevented. Lots of studies that we can prevent a good percentage of PPD: self care, support, sleep. Needs to be included in prenatal classes. We need policy change (paid maternity leave in the US!). Need to address partner treatment (male/female).