PDF file 1

Update on Postnatal
Depression
Lee Tak Shing, Dominic
MBChB!Hons", MD, MRCPsych, FHKAM, FHKCPsych
PND
Normal adjustment
Transient & mild
Understandable
Blues
Transient & mild
PND
11# prevalence 6 wks pp
5000+ PND each year
Persistent
Dysfunctional
Out of proportion
Postpartum psychosis
Voices, delusions
Onset usu w/in 2 wks
What is PND?
Mood disorders
Out of control: “malignant sadness”
Persistent !>2 wks"
Severe !# of symptoms"
Functional impairment
Textbook Symptoms
Low mood, lack of enjoyment
Lack of interest, lack of drive
Lack of energy
Insomnia
Retardation
Poor appetite, weight loss
Impaired concentration
Negative cognitions
Suicidal ideas
Local Symptoms
Special Symptoms
•
Tearfulness
•
Irritability
•
Unexplained medical symptoms
•
Anger
•
Excessive worries of infant health
•
悶
•
Admissions with no medical diagnosis
•
辛苦
Eliciting symptoms
•
Illness Experience
Probing questions
•
•
•
•
How do you sleep?
How are you coping? Baby easy to look after?
How was the zuoyue arranged?
It is common to feel depressed and stressed in first few
days. Have you ever had such experience?
How to diagnose PPD?
DSM criteria
5 symptoms x >=2 weeks + dysfunction
Real life
Persistent symptoms !day in, day out"
Dysfunctional
Loss of control !not my usual self"
Distress
Early morning wakening, retardation, or suicidal
ideas
Suicidal ideas !don’t panic!"
1.
2.
3.
4.
Not worth living
Vague, fleeting ideas
Plan
Action
Risk Factors
Gene x Environment interaction
Lack of social support
Poor marital relationship and spousal violence
Concurrent life events
Past hx of depression, esp. in postpartum
Personality vulnerability
Infertility
Graves Disease
Expatriats?
13-week BDI (mean, 95% CI)
In$law is more important
than husband
Fewer PND for Women w
Peiyue
14
12
10
8
6
4
2
others
poor/very poor
mother-in-law relationship
Complications of PND
42# of HK PPD remained
depressed at 2 years
postpartum
How to identify PPD?
Sharpen clinical awareness
Screening scale
Maternal and paternal unemployment
•
Separation and divorce
•
Children emotional and behavioural disorder
•
Child abuse
•
Suicide
Screening Scales
•
•
•
•
Edinburgh Postnatal Depression Scale EPDS
• 10 items on mood symptoms
• past 7 days
• no somatic items
• one item on self harm ideas
• 9/10 cut$o% for HK Chinese women
• Item 1 & 3 reversely scored
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Cox, J.L. Holden, J.M. and Sagovsky, R. (1987).
Detection of postnatal depression.
Lee, D.T., etal (1997) Detecting postnatal depression in Chinese.
Antenatal depressive
symptoms are best predictor
of PPD
Br. J. Psychiatry 150: 782-786.
Br.J. Psychiatry 172: 433-437.
Postnatal Depression is a
Misnomer
•
Antenatal depressive symptomatology is one of
the most powerful predictors of PND
•
Substantial proportion of postnatal depression
begins in the pregnancy
•
Antenatal depression shared similar risk factors
with postnatal depression
•
Perinatal depression rather than postnatal
depression is a more accurate description of the
psychopathology
Epidemiology
•
•
•
•
AN depression is associated with PND
•
Maternal neglect and poorer AN care
•
Alcoholism and drug abuse
•
Maternal anxiety increases uterine artery
resistance
•
low risks, esp 2nd trimester
Contemporary epidemiologic studies showed 10#
$ 20# prevalence
•
Adverse consequences
•
Fallacy of protected pregnancy in traditional
teachings
US, UK, Australia, Japan, Portugal, Uganda
Hormonal protection is a myth
Adverse consequences
•
Growth retardation
•
Lower birth weight and born early
•
SGA
•
preclampsia
•
Inferior performance on neonatal behavioural
assessment
•
Attention deficit and hyperactivity
Higher rate of Caesarean section
Risk Factors
•
past abortion, miscarriage, infertility
•
reject pregnancy and considered abortion
•
past depression or psychiatric history
•
medical history or complications
•
marital status, immigrants, education,
employment, income, financial di&culties
•
poor social support, life events, marital discord
•
drug and alcohol abuse
6# of HK mothers have
antenatal depression
AN Depression Symptoms
AN Depression assoc w
more epidural, C$section, pre$
term, SGA, pre$eclampsia
•
Broken sleep !not related to nocturia"
•
Lack of appetite, poor weight gain
•
Irritability, poor temper, tearfulness
•
Depressed mood, anxiety, panic attacks
•
Negative thoughts, excessive worries !e.g. fetal
malformation"
•
Atypical somatic symptoms
Treatment
•
Antidepressants
•
Head$Start Programme
•
•
Serotonin Selective Reuptake Inhibitor
• Fluoxetine !Prozac", Sertraline !Zoloft", Escitalopram !Lexapro"
• Paroxetine !Seroxat" $$$ fetal abnormality
• STAR*D study
SNRI
• Venlafaxine, Mirtazepine
Tricyclics
• Amitriptyline, Nortriptyline !breast feeding"
Treatment
STAR*D Results: Unresolved Depression Symptoms
More than 2/3 of patients had unresolved symptoms
67%
STAR*D Study (N=2,876)
10
Mild symptoms
!28%
Remission
!33%
9
8
Moderate
symptoms
!23%
Severe symptoms Very severe symptoms
!12%
!4%
•
Antidepressants
•
7
6
%
5
4
•
3
2
1
•
0
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Depressive symptoms (QIDS-SR score) after up to 12 wk antidepressant treatment
Serotonin Selective Reuptake Inhibitor
• Fluoxetine !Prozac", Sertraline !Zoloft", Escitalopram !Lexapro"
• Paroxetine !Seroxat" $$$ fetal abnormality
• STAR*D study
SNRI
• Venlafaxine, Mirtazepine, Duloxetine
Tricyclics
• Amitriptyline, Nortriptyline !breast feeding"
Adapted from Trivedi MH, et al. Am J Psychiatry. 2006;163:28-40.
Length of Randomized, Double-Blind,
Placebo-Controlled Studies in Relapse
and Recurrence
Treatment
6 Months
1 Year
2 Years
Venlafaxine XR1-3*
!
!
!
Duloxetine4
!
Escitalopram5
!
Bupropion6
!
Sertraline7,8
!
!
†
Paroxetine9
!
!
‡
•
Antidepressants
•
!
!= demonstrated relapse/recurrence prevention at end point.
•
*In the venlafaxine XR study, patients had at least 3 prior episodes of depression in their lifetime.
†Sertraline has been studied in 2-year recurrence prevention as monotherapy but failed to show a significant difference vs. placebo at end point.
‡Paroxetine has been studied in 2-year recurrence prevention in combination with psychotherapy/clinical management sessions with or without
augmentation, but not as monotherapy. In patients with recurrent depression, no significant difference was seen between paroxetine and
placebo.
1.
2.
3.
4.
5.
6.
7.
8.
9.
•
Simon JS, et al. J Psychiatr Res. 2004;38:249-257.
Montgomery SA, et al. J Clin Psychiatry. 2004;65:328-336.
Data on file, Wyeth Pharmaceuticals Inc.
Detke MJ, et al. Eur Neuropsychopharm. 2004;14:457-470.
Rapaport MH, et al. J Clin Psychiatry. 2004;65:44-49
Weihs KL, et al. Biol Psychiatry. 2002;51:753-761.
Keller MB, et al. JAMA. 1998;280:1665-1672.
Wilson KCM, et al. Br J Psychiatry. 2003;182:492-497.
Reynolds CF, et al. N Engl J Med. 2006;354:1130-1138.
Neonatal Withdrawal
Syndrome
Side E%ects
•
•
•
•
•
•
•
Serotonin Selective Reuptake Inhibitor
• Fluoxetine !Prozac", Sertraline !Zoloft", Escitalopram !Lexapro"
• Paroxetine !Seroxat" $$$ fetal abnormality
• STAR*D study
SNRI
• Venlafaxine, Mirtazepine, Duloxetine
Tricyclics
• Amitriptyline, Nortriptyline !breast feeding"
Nausea, insomnia, agitation, anxiety
Warn and be sensitive about “sexual repulsiveness”
No long term side e%ects
Discontinuation syndrome !slow withdrawal"
•
Health Canada warning Aug 9 2004
•
feeding and or breathing di&culties, seizures,
muscle rigidity, jitteriness, constant crying
•
bupropion, citalopram, fluoxetine, fluvoxamine,
mirtazapine, paroxetine, sertraline, venlafaxine
•
careful weighting of pros and cons is important
2 weeks onset !start treatment asap"
Persistence !“investment”"
Family supervision
ORIGINAL CONTRIBUTION
Relapse of Major Depression During
Pregnancy in Women Who Maintain
or Discontinue Antidepressant Treatment
SSRI in Pregnancy
•
Early pregnancy
•
•
Lee S. Cohen, MD
Lori L. Altshuler, MD
Bernard L. Harlow, PhD
Ruta Nonacs, MD, PhD
D. Jeffrey Newport, MD
Adele C. Viguera, MD
Rita Suri, MD
Vivien K. Burt, MD, PhD
Victoria Hendrick, MD
Alison M. Reminick, BA
Ada Loughead, BA
Allison F. Vitonis, BA
Zachary N. Stowe, MD
Ventricular septal defect
P
Pulmonary hypertension of the newborn
•
Neonatal withdrawal syndrome
Objective To describe risk of relapse in pregnant women who discontinued antidepressant medication proximate to conception compared with those who maintained
treatment with these medications.
REGNANCY HAS HISTORICALLY
been described as a time of
emotional well-being, providing “protection” against psychiatric disorder.1,2 However, systematic data to support this impression are
sparse. A prospective communitybased study described similar rates of
depression in gravid and nongravid
women3 and, more recently, a second
study noted the persistence of depressive symptoms during pregnancy.4
The high risk of depressive relapse
following discontinuation of maintenance antidepressant therapy in nongravid patients treated with antidepressants has been well established. 5
The determination of risk of relapse following discontinuation of antidepressants during pregnancy or in those
women who maintain treatment with
these medications during pregnancy has
not been previously investigated. Cli-
Late pregnancy
•
Context Pregnancy has historically been described as a time of emotional wellbeing, providing “protection” against psychiatric disorder. However, systematic delineation of risk of relapse in women who maintain or discontinue pharmacological
treatment during pregnancy is necessary.
Design, Setting, and Patients A prospective naturalistic investigation using longitudinal psychiatric assessments on a monthly basis across pregnancy; a survival analysis was conducted to determine time to relapse of depression during pregnancy. A total
of 201 pregnant women were enrolled between March 1999 and April 2003 from 3
centers with specific expertise in the treatment of psychiatric illness during pregnancy. The cohort of women was recruited from (1) within the hospital clinics, (2) selfreferral via advertisements and community outreach detailing the study, and (3) direct referrals from the community. Participants were considered eligible if they (1) had
a history of major depression prior to pregnancy, (2) were less than 16 weeks’ gestation, (3) were euthymic for at least 3 months prior to their last menstrual period, and
(4) were currently or recently (!12 weeks prior to last menstrual period) receiving antidepressant treatment. Of the 201 participants, 13 miscarried, 5 electively terminated their pregnancy, 12 were lost to follow-up prior to completion of pregnancy,
and 8 chose to discontinue participation in the study.
Main Outcome Measure Relapse of major depression defined as fulfilling Structured Clinical Interview for DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] Diagnosis (SCID) criteria.
Results Among the 201 women in the sample, 86 (43%) experienced a relapse of
major depression during pregnancy. Among the 82 women who maintained their medication throughout their pregnancy, 21 (26%) relapsed compared with 44 (68%) of
the 65 women who discontinued medication. Women who discontinued medication
relapsed significantly more frequently over the course of their pregnancy compared
with women who maintained their medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P!.001).
Conclusions Pregnancy is not “protective” with respect to risk of relapse of major
depression. Women with histories of depression who are euthymic in the context of
ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation.
nicians need such information to collaborate effectively with patients to tailor careful risk-benefit assessments with
regard to antidepressant drug use for
©2006 American Medical Association. All rights reserved.
Management
•
Antidepressants Vs. Psychotherapy
•
Balance the risk between
•
Fetal safety: teratogenicty and neurobehavioral
toxicity
•
Suicidal risk and adverse physical e%ects of
depression
•
Speedy recovery
www.jama.com
JAMA. 2006;295:499-507
Author Affiliations are listed at the end of this article.
Corresponding Author: Lee S. Cohen, MD, Perinatal
and Reproductive Psychiatry Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital, WACC 812, 15 Parkman St, Boston, MA
02114 (lcohen2@partners.org).
(Reprinted) JAMA, February 1, 2006—Vol 295, No. 5 499
Treatment
•
Psychosocial
•
Marital counselling !most husbands are just
ignorant", in$law conflicts
•
Maid, letters, CSSA, rehousing, …
•
Sick leaves