Psychiatric Complications of Pregnancy and the Postpartum

Psychiatric Complications of Pregnancy and the Postpartum
By:Joseph Breuner, MD
Swedish Family Medicine Residency

Objectives
    * Appreciate the postpartum period as a time of increased vulnerability to psychiatric illness
    * Recognize and diagnose psychiatric illness during pregnancy and the postpartum
    * Understand risks to the fetus of psychiatric medications
    * Prevent and treat psychiatric illness in pregnancy and the postpartum

Outline 1
    * Review DSM-IV diagnoses
    * Psychiatric illness during pregnancy
    * Psychiatric illness in the postpartum

But first, a review
DSM-IV Definition of...

    *   For at least one week (or less, if hospitalized) the patient's mood is
    *   abnormally and persistently high, irritable or expansive.
    *   To a material degree during this time, the patient has persistently had 3 or
    *   more of these symptoms (4 if the only abnormality of mood is irritability):
    *   -Grandiosity or exaggerated self-esteem
    *   -Reduced need for sleep

    *   -Increased talkativeness
    *   -Flight of ideas or racing thoughts
    *   -Easy distractibility
    *   -Psychomotor agitation or increased goal-directed activity (social, sexual,
    *   work or school)
    *   -Poor judgment (as shown by spending sprees, sexual adventures, foolish
    *   investments)

DSM-IV
    * Manic episode
DSM-IV definition of...
    * In the same 2 weeks, the patient has had 5 or more of the following symptoms,
    *   which are a definite change from usual functioning. Either depressed mood or
    *   decreased interest or pleasure must be one of the five.
    *   -Mood. For most of nearly every day, the patient reports depressed mood or
    *   appears depressed to others.
    *   -Interests. For most of nearly every day, interest or pleasure is markedly
    *   decreased in nearly all activities (noted by the patient or by others).
    *   -Eating and weight. Although not dieting, there is a marked loss or gain of
    *   weight (such as five percent in one month) or appetite is markedly decreased
    *   or increased nearly every day.
    *   -Sleep. Nearly every day the patient sleeps excessively or not enough.
    *   -Motor activity. Nearly every day others can see that the patient's activity
    *   is agitated or retarded.
    *   -Fatigue. Nearly every day there is fatigue or loss of energy.
    *   -Self-worth. Nearly every day the patient feels worthless or inappropriately
    *   guilty. These feelings are not just about being sick; they may be delusional.
    *   -Concentration. Noted by the patient or by others, nearly every day the
    *   patient is indecisive or has trouble thinking or concentrating.
    *   -Death. The patient has had repeated thoughts about death (other than the fear
    *   of dying), suicide (with or without a plan) or has made a suicide attempt.
    * Major Depressive Episode
    * For at least 4 days the patient has a distinct, sustained mood that is
    *   elevated, expansive or irritable. This is different from the patient's usual
    *   nondepressed mood.
    *   During this time, the patient has persistently had 3 or more of the following
    *   symptoms (4 if the only abnormality of mood is irritability). They have been
    *   present to an important degree.
    *   -Grandiosity or exaggerated self-esteem
    *   -Reduced need for sleep
    *   -Increased talkativeness
    *   -Flight of ideas or racing thoughts
    *   -Easy distractibility
    *   -Psychomotor agitation or increased goal-directed activity (social, sexual,
    *   work or school)
    *   -Poor judgment (as shown by spending sprees, sexual adventures, foolish
    *   investments)
    * Hypomanic episode
    * The patient suddenly develops a severe fear or discomfort that peaks within 10
    *   minutes.
    *   During this discrete episode, 4 or more of the following symptoms occur:
    *   -Chest pain or other chest discomfort
    *   -Chills or hot flashes
    *   -Choking sensation
    *   -Derealization (feeling unreal) or depersonalization (feeling detached from
    *   self)
    *   -Dizzy, lightheaded, faint or unsteady
    *   -Fear of dying
    *   -Fears of loss of control or becoming insane
    *   -Heart pounds, races or skips beats
    *   -Nausea or other abdominal discomfort
    *   -Numbness or tingling
    *   -Sweating
    *   -Shortness of breath or smothering sensation
    *   -Trembling
    * Panic Attack
    * The patient must have all of:
    *   1 Recurring, persisting thoughts, impulses or images inappropriately intrude
    *   into awareness and cause marked distress or anxiety.
    *   2 These ideas are not just excessive worries about ordinary problems.
    *   3 The patient tries to ignore or suppress these ideas or to neutralize them by
    *   thoughts or behavior.
    *   4 There is insight that these ideas are a product of the patient's own mind.
    * Obsessions
    * The patient must have all of:
    *   1 The patient feels the need to repeat physical behaviors (checking the stove
    *   to be sure it is off ,handwashing) or mental behaviors (counting things,
    *   silently repeating words).
    *   2 These behaviors occur as a response to an obsession or in accordance with
    *   strictly applied rules.
    *   3 The aim of these behaviors is to reduce or eliminate distress or to prevent
    *   something that is dreaded.
    *   4 These behaviors are either not realistically related to the events they are
    *   supposed to counteract or they are clearly excessive for that purpose.
    * Compulsions
    * For more than half the days in at least 6 months, the patient experiences
    *   excessive anxiety and worry about several events or activities.
    *   The patient has trouble controlling these feelings.
    *   Associated with this anxiety and worry, the patient has 3 or more of the
    *   following symptoms, some of which are present for over half the days in the
    *   past 6 months:*
    *   -Feels restless, edgy, keyed up
    *   -Tires easily
    *   -Trouble concentrating
    *   -Irritability
    *   -Increased muscle tension
    *   -Trouble sleeping (initial insomnia or restless, unrefreshing sleep)
    * Generalized Anxiety Disorder
First Case
    * Your patient veronica is the director of entertainment on a cruise ship. She wants to have a baby but her boyfriend is worried that pregnancy will make her crazy, or at least make her more likely to have a mental illness. Is psychiatric illness more common in pregnancy?
Pregnancy and Psychiatric Morbidity
    * In general population, pregnancy confers no risk or benefit of developing a psych diagnosis, except that 25% of new OCD cases start in pregnancy
    * In patients with prior psych history, relapse risk is unaffected by pregnancy, except that
    * panic disorder may improve
Veronica
    * It turns out that veronica has had two episodes of major depression. Will pregnancy increase her relapse risk?
Relapse risk during pregnancy same as nonpregnant

First Case, Again
    * Three months later, Veronica is pregnant.She would like to know which classes of psych meds are dangerous for her baby, so that when she sails to Asia on her next cruise she can obtain treatment with confidence.
    * Extra credit question: in which trimester?
Teratogenic Risk from Tricyclic Exposure
Teratogenic Risk of SSRI exposure
Neurodevelopmental  Risk of SSRI exposure
    * Long term risk
Teratogenicity of Lithium
    * Lithium and Ebstein’s anomaly
Teratogenicity of Depakote and Tegretol
Teratogenic Risks of Benzodiazepines
Why take Paxil?
Neonatal Risks of Untreated Depression and Anxiety
Neonatal risks of untreated depression/anxiety
Postpartum Psychiatric Morbidity
Neurophysiology of post partum period
Postpartum relapse rates are increased
Veronica, otra vez
Risk factors for postpartum psychiatric illness
Psych Syndromes in the Postpartum: Bipolar
Psych Syndromes in the Postpartum:Depression Diagnoses
Psych Syndromes in the Postpartum:Depression
Screening Questions for Postpartum Depression
Psych Syndromes in the Postpartum:Panic
Psych Syndromes in the Postpartum:Obsessive Compulsive Disorder
Psych syndromes in the postpartum: psychosis
Long term effects on children of mothers with untreated postpartum depression
    * What medications are safe for treating veronica’s depression?
Breastfeeding and Tricyclics
SSRI’s and Breastfeeding
Breastfeeding and Mood Stabilizers
Breastfeeding and Benzodiazepines
Prophylaxis of Postpartum Depression
Postpartum Depression: Risk Stratification and Prophylaxis
Resources for Support for the Mother
Resources for Support for the Mother
    * http://www.ppmdsupport.com/
Objectives
     * Appreciate the postpartum period as a time of increased vulnerability to psychiatric illness
    * Recognize and diagnose psychiatric illness during pregnancy and the postpartum
    * Understand risks to the fetus of psychiatric medications
    * Prevent and treat psychiatric illness in pregnancy and the postpartum

Psychiatric Complications of Pregnancy and the Postpartum