women

Management of Psychiatric Disorders in Pregnant and Postpartum Women Director(s): Shaila Misri, M.D., Diana Carter, M.D. Date: Monday May 7, 2012 Time: 1pm-5pm Location: 204 C, Level 2, Convention Center

Course 39 American Psychiatric Association • Integrated Care • Philadelphia, May 5-9, 2012 • 165th Annual Meeting

Course 39 Course Faculty

Shari Lusskin, M.D. Deirdre Ryan, M.D.

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Agenda The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s).

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Management of Psychiatric Disorders in Pregnant and Postpartum Mothers

Director Shaila Misri, M.D. Co- Director Diana Carter, M.B. Faculty Shari Lusskin, M.D, Deirdre Ryan, M.D.

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Course Agenda Date: Monday, May 7th, 2012 Time: 1:00pm – 5:00pm Introduction: The Provincial Reproductive Mental Health Program, BC Canada

Dr. Misri/Carter

1:00 –1:10

Lecture 1: Depression in Pregnancy and Postpartum

Dr. Ryan

1:10-1:45

Lecture 2: Psychopharmacology for Depression in Pregnant and Breastfeeding Women

Dr. Lusskin

1:45-2:15

COFFEE BREAK

ALL

2:15-2:30

Lecture 3: Anxiety Disorders in Pregnancy & Postpartum

Dr. Carter

2:30-3:05

Lecture 4: Bipolar Disorders in Pregnancy and Postpartum

Dr. Misri

3:05-3:40

Question and Answer Session

Open Panel

3:40-4:55

Course Evaluation and Conclusions

Dr. Misri/Carter

4:55-5:00

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

Outline The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s).

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Depression in Pregnancy and Postpartum Dr. Deirdre Ryan Clinical Instructor, Psychiatry University of British Columbia Medical Director & Psychiatrist, Reproductive Mental Health Program Vancouver, BC

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

DEPRESSION IN PREGNANCY AND POSTPARTUM

OUTLINE: Dr. Deirdre Ryan Objectives BC Reproductive Mental Health Program Depression in Pregnancy Risks of Untreated Depression in Pregnancy on the Fetus & Infant Spectrum of Postpartum Mood Changes Epidemiology Risk Factors Symptoms Comorbidity Implications of Maternal Depression on Mother & Child Remission of Maternal Depression Benefits Children What about Fathers?

Screening for Perinatal Depression Pharmacological Treatment of Perinatal Depression Non-Pharmacological Treatments of Perinatal Depression Clinical Guidelines for Depression in Pregnancy and Postpartum Resources

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Psychopharmacology for Depression in Pregnancy and Lactation Dr. Shari Lusskin Director of Reproductive Psychiatry NYU Langone Medical Center Clinical Associate Professor of Psychiatry, Obstetrics, and Gynecology New York University School of Medicine

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Psychopharmacology for Depression in Pregnant and Breastfeeding Women Outline- Dr. Shari Lusskin 1. Objectives 2. Practice of Evidence Based Medicine 3. Fetal Program Hypothesis 4. Perinatal Relapse Rates 5. Medication Concerns 6. Limitations of Available Data 7. FDA Warnings & Labelling 8. Antidepressants & Teratogenicity 9. Neonatal Complications 10. Persistent Pulmonary Hypertension 11. SSRI’s & TCA’s: Neurodevelopment 12. Controversy: SSRI’s & Autism 13. Medication Dosing 14. Benzodiazepines & Non-Benzodiazepine Hypnotics 15. Breastfeeding 16. Summary

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Anxiety Disorders in Pregnancy and Postpartum

Dr. Diana Carter Psychiatrist Reproductive Mental Health Program Vancouver, BC

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Anxiety Disorders in Pregnancy & Postpartum Outline: Dr. Diana Carter 1. Introduction 2. Effects of Maternal Anxiety Disorders on the Fetus & Child 3. Panic Disorder in the Perinatal Period · · · · · ·

Prevalence Infant & Maternal Outcomes Presentation Onset/Course Differential Diagnosis Treatment

4. Obsessive Compulsive Disorder · · · · · ·

Prevalence Onset/ Course Presentation Obsessions & Compulsions Effects on Infant Treatment

5. Post Traumatic Stress Disorder · · · ·

Prevalence Presentation/ Predictors Risk Factors Treatment

6. Generalized Anxiety Disorder · · · · ·

Prevalence Presentation/ Predictors Worry Themes Onset/ Comorbidity Treatment

7. Summary

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Bipolar Disorders in Pregnancy and Postpartum

Dr. Shaila Misri Founding Director of the Reproductive Mental Health Program, B.C. Women’s Hospital Director of Research & Education Clinical Professor Psychiatry and OB/GYN University of British Columbia

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

BIPOLAR DISORDERS IN PREGNANCY AND POSTPARTUM

Outline- Dr. Shaila Misri Objectives Bipolar Disorder in Pregnancy & Postpartum 1.

2.

3.

4.

5.

6.

7.

8.

9.

Bipolar Spectrum Disorder Assessment Diagnosis Risk Factors Presentation Suicide Infanticide Principles of Treatment Pharmacotherapy a. Switching Phenomenon b. Development of Fetus c. Teratogenicity d. Relapse & Discontinuation e. Mood Stabilizers & (Atypical) Antipsychotics 10. Lactation 11. ECT

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

Slides The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s).

Depression in Pregnancy & Postpartum Dr. Deirdre Ryan Assistant Professor, Psychiatry University of British Columbia Senior Psychiatrist, Reproductive Mental Health Program

APA 2012

1

Disclosure Clinical trials or studies

•Astra-Zeneca •Lundbeck •Pfizer

Honoraria or other fees

•Astra- Zeneca

2

What is the BC Reproductive Mental Health Program?

• Tertiary mental health clinic in Vancouver located at BC Women’s Hospital (part of BC Mental Health & Addiction Services) • Over 4,000 patient visits/year • Multidisciplinary team: psychiatrists, nurse clinician, social worker, clinical counselors, dietitian, outreach coordinator, researchers, students • 80% of referrals for perinatal depression & anxiety • also see women for mental health problems associated with PMS/PMDD, pregnancy loss, infertility, menopause, etc.

• involved in research & education

3

Objectives (a) Identify women at risk of developing major depression during pregnancy and the postpartum period (b) Understand how psychiatric illness can effect long-term outcomes in mothers and babies (c) Screen for major depression in pregnancy & the postpartum

4

Depression During Pregnancy Antenatal depression is under-recognized and under-treated: • Symptom overlap can make diagnosis difficult (e.g. sleep, appetite and energy changes) • One study found only 26% of known cases of antenatal depression were identified during prenatal health care visit. Only 2% were referred for treatment.

Hostetter AL & Stowe ZN. In: Emerging treatments and research. Washington (DC): American Psychiatric Publishing Inc., 2002:133-56 Josefsson A et al. Acta Obstet Gynecol Scand. 2001; 80:251-55 Smith M et al. Psychitr Serv. 2004; 55(4): 407-14

5

Depression in Pregnancy • Prevalence of Depressive Disorder during pregnancy: 14 – 23% • Postpartum depression often has its onset in pregnancy • For women of childbearing age, depression is the leading cause of disease burden worldwide (WHO 2001)

Gaynes BN et al. Evid Rep/Technol Assess (Summ). 2005; 119:1-8 Cox JL et al. Br J Psychiatry. 1993; 163:27-31 Josefsson A et al. Acta Obstet Gynecol Scand. 2001; 80:251-55 Bennett HA et al. Obstet Gynecol 2004; 103:698-709 Evans J et al. BMJ 2001; 323(7307):257-60

6

Risks of Untreated Depression in Pregnancy • Poor prenatal care • Risk of medical / obstetrical complications e.g.

Hyperemesis Gravidarum and Pre-Eclampsia • Self-medication / substance abuse • Impaired bonding • Postpartum Exacerbation

Marcus SM et al. J Womens Health. 2003; 12:373-80 Orr ST et al. Pediatric & Perinatal Epidemiology 2000; 14:309-13 National Institute of Mental Health. Mental disorders in America.

Available at: www.nimh.nih.gov/publicat/numbers/cfm Lindahl V et al. Arch Women’s Mental Health. 2005; 8:77-87.

7

Risks of Depression in Pregnancy on the Developing Fetus / Infant Risk of Preterm Birth • Risk of Low Birth Weight • relative R frontal EEG Asymmetry • fussiness and crying / ↓ time awake and alert

•

Diego MA et al. Psychiatry. 2004; 67(1):63-80 Diego MA et al. J Pediatr. 2005; 147(1):50-5 Grote NK et al. Arch Gen Psychiatry. 2010; 67(10):1012-24.

8

Spectrum of Postpartum Mood Changes Serious, disabling

Transient, nonpathologic

100 80

%

60

Postpartum blues ď‚­ risk for MDD

Postpartum depression 50% to 70%

Postpartum psychosis

40 20

Psychiatric emergency

13%

ď‚ť0.1%

0

Cohen LS. Depress Anxiety. 1998; 8(1):18-26

9

Epidemiology of Postpartum Depression (PPD) •

DSM-IV TR: PPD within 4 weeks after birth

•

Clinically: PPD within 12 months of childbirth

•

Mean prevalence rate of 13%

American Psychiatric Association. DSM-IV-TR. Washington, DC: American Psychiatric Assocation, 2000 Gavin N et al. Obstet Gynecol. 2005; 106:1071-83 O'Hara MW et al. Int Rev Psychiatry. 1996; 8:37-54

10

Biological Risk Factors for Perinatal Depression • Exact Pathogenesis of Perinatal Depression is Unknown • ? Related to HPA axis changes in response to stress • ? Related to Estrogen and Progesterone dysregulation • ? Related to Genetic and Epigenetic factors

Meltzer-Brody S. Dialogues Clin Neurosci. 2011;13:89-100

11

Biological Risk Factors for Perinatal Depression • Prior history of a MDD/ PMDD/ PPD** • Psychiatric illness in family members • Discontinuation of antidepressants • Significant medical / obstetrical problems e.g. Gestational Diabetes or Preeclampsia (** Pts with a hx of PPD have a 25 – 50% recurrance of PPD) Altshuler LL et al. J Clin Psychiatry. 1998; 59:29-33 Einarson A. Am J Psychiatry. 2001; 158:1728-30 Magiakou MA et al. J Clin Endocrinol. 1996; 81:1912-17 Robertson E et al. Gen Hosp Psychiatry. 2004; 26:289-95 Steiner M et al. J Affect Disord. 2003; 74:67-83 Kozhimannil KB et al. JAMA. 2009;301(8):842-7 Yim IS et al. Arch Gen Psychiatry. 2009; 66(2):162-9.

12

Psychosocial Risk Factors for Perinatal Depression • • • • • • • • •

Unplanned pregnancy Lack of partner, family and social support Stressful life events Multiple Births Breastfeeding difficulties Colicky babies / infant health problems Socio-economic status Abuse Issues Cultural Issues, including Immigrant Status Altshuler LL et al. J Clin Psychiatry. 1998; 59(Suppl 2):29-33 Robertson E et al. Gen Hosp Psychiatry. 2004; 26:289-95 Choi Yet al. Pediatrics. 2009; 123(4):1147-54

13

Symptoms unique to Postpartum Depression • Lack of enjoyment in the baby • Difficulty sleeping when baby is sleeping • Feelings of worthlessness and Guilt related to parenting • Obsessive thoughts of harming the baby • If suicidal, may believe that the baby would be better off with another mother

14

Co-Morbidity Remember: • Anxiety disorders • Eating disorders • Personality disorders.

15

Implications of PPD

16

Implications of PPD for the Mother-Infant Dyad • • •

Impaired mother-infant interaction • Withdrawn mother: fussy baby • Anxious, intrusive mother: detached baby Infants of Depressed Mothers less responsive to Faces and Voices Fathers may compensate for mother’s lack of attachment If mother requires admission to hospital, consider a Mother-Baby Unit to facilitate bonding Edhborg M et al. Arch Women Ment Health. 2003; 6:211-6 Weinberg KM & Tronik EZ. Pediatrics. 1998; 102:1298-304 Field T et al. Infant Behav Dev. 2009; 32(4):454-60

17

Effect of Maternal Depression on Children’s Growth and Behaviour •

Disturbance in Feeding Behaviours in Depressed Moms may result in: – Risk of Stunted Growth – Risk of Obesity

• Child Behavioural Problems @ Age 2 • Externalizing Behaviours @ Age 3 • Association varies with socioeconomic status

Avan B et al. Arch Dis Child. 2010; 95:690-5 Grote V et al. BMC Pediatrics. 2010; 10(1):14 Oberlander TF et al. Arch Pediatr Adolesc Med. 2010; 164(5):444-51

18

Implications of Maternal Depression • First Year of Child’s Life is “sensitive period” • Maternal Depression impacts psychological, social, cognitive and behavioral development in child • Chronic maternal depression results in higher rates of : – Anxiety Disorders ( ? mediated by

cortisol level)

– Depressive Disorders – Behavioral Disorders in toddlerhood, preadolescence and adulthood

• PPD associated with an ↑ risk of Child Abuse and Neglect Jacobsen T et al. J Child Psychol Psychiatry, 2000; 41(7):899-906; Murray L & Cooper P. Arch Dis Child. 1997; 77(2):99-101; Misri S et al. Am J Psychiatry. 2006; 163(3): 1026-32; Murray L et al. Br J Psychiatry 2003; 182:420-7; Weissman MM et al. JAMA. 2006; 295(12):1389-98; Buist A. Aust N Z J Psychiatry. 1998; 32(4):479-87; Brand SR & Brennan PA. Clin Obstet Gynecol. 2009:52(3):441-55; Bagner DM et al. JAACAP. 2010;49(7):699-707; Brennan PA et al. J Child Psychol Psychiatry. 2008;49(10):1099-107

19

Remission of Maternal Depression Benefits Children • 151 depressed mothers and their children (7-17 years) • Remission of maternal depression after 3 months of medication treatment was significantly associated with reductions in children’s depressive, anxiety and disruptive behavior disorders and symptoms.

Weissman MM et al. JAMA. 2006; 295(12):1389-98.

20

Implications of PPD for the Mother Biological Implications • Chronic, relapsing illness • Possible underlying Bipolar illness • Suicide (Rates in postpartum adolescents are higher than in older postpartum women) Psychosocial Implications • Relationship disruption • Marital problems (↑ risk of divorce) • Employment difficulties Beck CT. Nurs Res. 2001; 50:275-85 Lindahl V et al. Arch Womens Ment Health. 2005: 8(2):77-87 O'Hara MW et al. J Abn Psychology. 1991; 100(1):63-73 O’Hara MW & Swain A. Int Rev Psychiatry. 1996; 8:37-54 Rubersston C et al. Arch Womens Ment Health. 2005; 8(2):97-104 Holden JM. Birth. 1991; 18(4):211-21 Pearlstein T et al. AJOG. 2009;200(4):357-64 Appleby L. BMJ. 1991;302:137-40

21

What About Fathers?

New fathers may seem more angry and anxious than sad

Melrose S. Contemp Nurse. 2010; 34(2):199-210

22

What About Fathers?

•

Prevalence of PPD in fathers: 4 – 10%

•

Paternal depression shows moderate positive correlation with maternal depression

•

? Related to changes in testosterone and cortisol levels

•

Paternal depression is associated with: conduct problems and hyperactivity in children, especially males Ramchandani A et al. Lancet. 2005; 365(9478):2201-5 Paulson JF et al. Pediatrics. 2006; 118(2): 659-68 Kim P & Swain JE. Psychiatry (Edgmont) 2007 Feb;4(2):35-47 Paulson JF & Bazemore SD. JAMA. 2010; 303(19):1961-9

23

Screening for Perinatal Depression •

Pregnancy: between 28 - 32 weeks

•

Postpartum: Recommended times: • postpartum follow-up visits (British Columbia at 6 weeks) • baby’s immunization at 2 months

•

Screening tool: Edinburgh Postnatal Depression Scale (E.P.D.S. and E.P.D.S.-P )

•

Future Goals: Universal Screening for Anxiety Disorders Sit DKY & Wisner K. Cl Obs Gyn. 2009; 52(3):456-68 Austin MP. Arch Womens Ment Health. 2003; 7:1-6 Dennis CL. J Affect Disord. 2004; 78:163-9

24

Treatment of Perinatal Depression  Many women refuse medication for psychiatric illness during pregnancy and postpartum because of concerns about exposing the baby to the medication.  What other treatments can we offer?

25

Non- Pharmacological Treatments of Perinatal Depression • Psychological Interventions: • Psychoeducation* • Cognitive Behavioural Therapy • Interpersonal Psychotherapy • Group Therapy

• Other Therapies: • Bright Light Therapy • rTMS • E.C.T. • Infant Massage

Field T et al. Infant Behav Dev. 2009; 32(4):454-60 Moses-Kolko EL et al. Clin Obstet Gynecol. 2009; 52(3):516-29

26

Complementary and Alternative Strategies • • • • • • • • •

St John’s Wort SAMe Acupuncture Massage Yoga Music Exercise Nutritional Interventions (O-3FAs) Herbal Preparations Deligiannidis KM & Freeman MP. Psychiatr Clin North Am. 2010; 33(2):441-63 Manber R et al. Obstet Gynecol. 2010; 115(3):511-20 Ng RC et al. Pharmacotherapy. 2010; 30(9):927-41

27

Psychological Interventions • Meta Analysis ( Cuijpers et al,2008) : Different types of Psychological Interventions are about equally effective in treating PPD

28

Cognitive Behavioural Therapy (CBT) • Research on CBT for the treatment of depression in pregnancy and postpartum is sparse • Chabrol et al.,2002: 5-8 sessions of In-Home CBT resulted in recovery in 66.6% v. 6.6% in control group • Highet and Drummond (2004): CBT was equally effective as medication for treatment of symptoms of depression, psychological anxiety and physiological anxiety postpartum • Misri S et al., 2004: Combined CBT and antidepressants: No advantage in receiving both

29

Adaptation of CBT in Treatment of Perinatal Depression • Establish collaborative therapy relationship • Educate about symptoms and instill hope • Identify dysfunctional thinking patterns e.g. need to be “perfect mother” • Set realistic goals and homework assignments • Practical assistance in mobilizing support http://www.bcwomens.ca/Services/HealthServices/ReproductiveMental Health/SelfCareGuide.htm

30

31

Interpersonal Therapy (IPT) for Depression • Problem areas selected for focus of treatment: • • • •

grief role transition interpersonal role disputes interpersonal deficits

Ideal in depressed pregnant and postpartum women where role transition is a significant issue

32

Motherhood: Role Transitions Working

At home

Status of Working woman

“Lower” status of “stay-at-home” mum

Independent

Dependent on neonate’s schedule

Financial Independence In control

Dependent on partner’s $$$ Out-of-control- baby dictates schedule

33

Efficacy Antepartum and Postpartum Depression  Significant improvement using IPT vs. control  One study found additional improvement in marital function and perception of the mother-infant relationship

Prevention Antenatal abbreviated treatment:  Acute response  Sustained at 6 months  ↓ PPD in at risk women with preventative IPT/CBT Grote NK et al. Res Soc Work Pract. 2004; 14:397-407 Klier CM et al. J Psychother Pract Res. 2001; 10(2):124-31 O’Hara MW et al. Arch Gen Psychiatry. 2000; 57:1039-45 Spinelli MG & Endicott J. Am J Psychiatry. 2003; 160:555-62 Zinga D et al. Rev Bras Psiquiatr. 2005; 27:S56-64 Mulcahy R et al. Arch Womens Ment Health. 2010; 13(2):125-39 Grote NK et al. Psychiatry Serv. 2009; 60(3):313-21

34

Group Therapy  Self-help: Post Partum Support International OR  Therapist facilitated  Group CBT very effective for PPD  In practice a combination of techniques often used : (Supportive, cognitive and psychodynamic techniques) Clark R et al. Am J Orthopsychiatry. 2003; 73:441-54 Meager I & Milgrom J. Aust N Z J Psychiatry. 1996; 30:852-60 Morgan M et al. J Adv Nurs. 1997; 26:913-20 Dimidjian S & Goodman S. Clin Obstet Gynecol. 2009; 52(3):498-515 Honey KL et al. Br J Clin Psychol. 2002;41:405-9

35

Therapy Groups at Reproductive Mental Health Program • • • • • • • •

Postpartum Depression Therapy Group Mother and Infant Bonding Group Parenting Skills Group Optimistic Thinking Group Mindfulness and Relaxation Group Raising Your Self Esteem using C.B.T. Women and Anger Group Couples Workshop

36

Clinical Guidelines for Perinatal Depression All women should be screened for depression in pregnancy Accurate diagnosis and referral to mental health professionals

Universal screening and follow-up postpartum Monitor mother- infant interaction Maintenance & Relapse Prevention

37

Lesson Learned

Early identification & treatment of psychiatric illness in the perinatal period can optimize maternal/neonatal outcomes

38

Resources BC Reproductive Mental Health Program www.bcrmh.org or www.bcwomens.ca Pacific Postpartum Support Society www.postpartum.org Postpartum Support International http://www.postpartum.net/

39

Edinburgh Postnatal Depression Scale 1 (EPDS) Name: ______________________________

Address: ___________________________

Your Date of Birth: ____________________

___________________________

Baby’s Date of Birth: ___________________

Phone:

_________________________

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

Here is an example, already completed.

I have felt happy: Yes, all the time Yes, most of the time No, not very often No, not at all

This would mean: “I have felt happy most of the time” during the past week.

Please complete the other questions in the same way.

In the past 7 days: 1. I have been able to laugh and see the funny side of things As much as I always could Not quite so much now Definitely not so much now Not at all 2. I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all *3. I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never 4.

*5

I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not at all

*6. Things have been getting on top of me Yes, most of the time I haven’t been able to cope at all Yes, sometimes I haven’t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever *7

I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all

*8

I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all

*9

I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never

*10

The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never

Administered/Reviewed by ________________________________ Date ______________________________ 1

Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale.

British Journal of Psychiatry 150:782-786 .

2

Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199 Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies.

Edinburgh Postnatal Depression Scale 1 (EPDS) Postpartum depression is the most common complication of childbearing.2 The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective screening tool.

Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders.

Women with postpartum depression need not feel alone. They may find useful information on the web sites of the National Women’s Health Information Center <www.4women.gov> and from groups such as Postpartum Support International <www.chss.iup.edu/postpartum> and Depression after Delivery <www.depressionafterdelivery.com>.

SCORING QUESTIONS 1, 2, & 4 (without an *) Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3.

QUESTIONS 3, 5­10 (marked with an *) Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0.

Maximum score: 30 Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts)

Users may reproduce the scale without further permission, providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies.

Instructions for using the Edinburgh Postnatal Depression Scale: 1. The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days.

2. All the items must be completed.

3. Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.)

4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

1

Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.

2

Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199

Psychopharmacology for Depression in Pregnancy and Lactation: Evidence-based Decisions Shari I. Lusskin, MD Departments of Psychiatry, Obstetrics, Gynecology, and Reproductive Sciences Mt. Sinai School of Medicine

APA 2012 Philadelphia, PA

1

Shari I. Lusskin, MD Disclosure • Consultant: – The Reproductive Toxicology Center, A Non-Profit Foundation – www.reprotox.org • Author and Peer Reviewer: UpToDate – www.uptodate.com • Website: www.drsharilusskin.com • Off-label use of medication will be discussed

2

Objectives – To recognize that untreated and under-treated illness has serious consequences – To use the best evidence to guide medication choices – To recognize that the “standard of care” is evolving

3

The Practice of Evidence-Based Medicine…..

• Integrates…

– the best external evidence – with individual clinical expertise – and patient preference

• …..to provide the best care possible for each individual patient

4

The Fetal Programming Hypothesis

(genetics)

(environment)

Van den Bergh BR et al. Neurosci Biobehav Rev. 2005; 29(2):237-58

5

Perinatal Relapse Rates Major Depression: Antenatal relapse rate < < Postnatal Relapse

Viguera AC et al. Am J Psychiatry. 2011; 168(11):1179-85

6

Patients who go off medications tend to relapse

7

Relapse of Major Depression Maintained Rx (n=104) Discontinued Rx (n=103)

1.0 0.9 0.8 0.7 Proportion of Women Remaining Euthymic

26%

0.6 0.5 0.4 0.3

68%

HR: 5.0 (2.8-9.1)

0.2 0.1 0.0 0

4

8

12

16

20

24

28

32

36

40

Weeks of Gestation Cohen LS et al. JAMA. 2006; 295(5):499-507

8

Medication Concerns • Teratogenicity – Background rate of birth defects: 2%-4%6% – Organogenesis occurs in 1st trimester • Brain: all 3 trimesters and beyond

• Neonatal complications • Neurobehavioral teratogenicity American College of Obstetrics and Gynecology Practice Bulletin No. 87. Obstet Gynecol. 2007; 110(5):1179-98 Misri S & Kendrick K. Can J Psychiatry. 2007; 52(8):489-98 Yonkers KA et al. Obstet Gynecol. 2009; 114(3):703-13.

9

Limitations of Available Data #1 • Case series: small size, lack of controls • Incomplete information on –Maternal diagnosis –tobacco, substance abuse –other medications –body mass index

10

Limitations of Available Data #2 • Retrospective vs. prospective studies • Rating heterogeneity and reporting bias

• Lack of validation of fetal exposure

11

FDA Warnings: SSRI and SNRI Antidepressants • Neonatal toxicity/withdrawal (2004) • Teratogenicity: paroxetine category D (2005) • 2011 FDA RETRACTED WARNING: Persistent pulmonary hypertension of the newborn

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm154975.htm http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM164864.pdf http://www.fda.gov/Drugs/DrugSafety/ucm283375.htm#data

12

FDA: New system proposed for pregnancy labeling • NO letter category • Pregnancy Registry information • General Statement about 1. Risk Assessment 2. Clinical Considerations 3. Data

http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/ucm093307.htm http://www.fda.gov/downloads/NewsEvents/Newsroom/MediaTranscripts/UCM169332.pdf

13

Antidepressants and Teratogenicity • Majority of studies show NO increased risk for any category – although some reports suggested a slight increase in risk for SSRIs and bupropion

• Paroxetine: Meta-analysis found NO association with heart defects 1) Källén BA & Olausson PO. Birth Defects Res A Clin Mol Teratol. 2007; 79(4):301-8; 2) Louik C et al. N Engl J Med. 2007; 356(26):2675-83 3) Alwan S et al. N Engl J Med. 2007;356(26):2684-92; 4) Diav-Citrin O et al. Brit J Clin Pharmacology. 2008; 66(5):695-705 5) Einarson A et al. Am J Psychiatry. 2008;165(6):749-52 6) Gentile S & Bellantuono C. J Clin Psychiatry. 2009; 70(3):414-22 7) Pedersen LH et al. Brit Med J. 2009; 339:b3569 8) Alwan S et al. Am J Obstet Gynecol. 2010; 203(1):52 e1-6 9) Pearson KH et al. J Clin Psychiatry. 2007; 68(8):1284-9 10) Einarson A et al. Am J Psychiatry. 2001; 158(10):1728-30 11) Klieger-Grossmann C et al. J Clin Pharmacol. 2011 [in press]

14

Neonatal Complications • Symptoms: –Jitteriness, tremor, respiratory difficulties, feeding and sleeping disturbances, hypoglycemia • Symptoms usually mild and resolve quickly • No long-term consequences at ages 8 months to 5 years 1) Chambers CD et al. N Engl J Med. 1996; 335(14):1010-15 2) Sanz EJ et al. Lancet. 2005; 365(9458):482-7 3) Moses-Kolko EL et al. JAMA. 2005; 293(19):2372-83 4) Levinson-Castiel R et al. Arch Pediatr Adolesc Med. 2006; 160(2):173-6 5) Oberlander TF et al. J Clin Psychiatry. 2004; 65(2):230-7 6) Misri S et al. Am J Psychiatry. 2006; 163(6):1026-32 7) Suri R et al. Am J Psychiatry. 2007; 164(8):1206-13 8) Miller LJ et al. J Clin Psychiatry. 2008; 69(2):323-4 9) Toh S et al. Am J Psych. 2009; 166(3):320-8 10) Wisner KL et al. Am J Psychiatry. 2009; 166(5):557-66 11) Maschi S et al. BJOG. 2008; 115(2):283-9 12) Lund N et al. Arch Pediatr Adolesc Med. 2009; 163(10);949-54

15

Neonatal Complications: WHY? • Nicotine withdrawal?

• Maternal mental illness severity?

• Medication exposure?

• History of childhood trauma?

16

Persistent Pulmonary Hypertension of the Newborn and SSRIs #1 • 2006: US case-control study – Odds Ratio 6.1 (95% CI 2.2-16.8) for exposure >20 wks • 2008: Swedish Medical Birth Registry – Relative Risk 3.6 (95% CI 1.2-8.3) for exposure at >34 wks • 2009: US health insurance database – No association with SSRI use in 3rd trimester • 2009: US Mayo Clinic Medical Records Review – No association with SSRI use in pregnancy • 2007: other risk factors for PPHN include: Maternal obesity, smoking, diabetes, Cesarean delivery, meconium aspiration Chambers CD et al. N Engl J Med. 2006; 354(6):579-87 Kallen B & Olausson PO. Pharmacoepidemiol Drug Saf. 2008; 17(8):801-6 Andrade SE et al. Pharmacoepidemiol Drug Saf. 2009; 18(3):246-52 Hernandez-Diaz S et al. Pediatrics. 2007; 120(2):e272-82 Wichman CL et al. Mayo Clin Proc. 2009; 84(1):23-7

17

Persistent Pulmonary Hypertension of the Newborn and SSRIs #2 • 2011 US case-control study – No association with SSRI use >20 wks • 2011 FDA retracts warning because of conflicting data • 2012 Nordic multinational records-linkage study – Odds Ratio 2.1 (95% CI 1.5-3.0) if filled an SSRI RX >20 weeks

Wilson KL et al. Am J Perinatol. 2011; 28(1):19-24 http://www.fda.gov/Drugs/DrugSafety/ucm283375.htm#data (accessed 12/14/11) Kieler H et al. BMJ. 2011; 344:d8012.

18

SSRIs and TCAs: Neurodevelopment • No differences in language, IQ, or behavior at 16 months – 7 years • Similar findings at age 4-5 years • Differences within groups correlate with severity of maternal depression

Nulman I et al. N Engl J Med. 1997; 336(4):258-2 Nulman I et al. Am J Psychiatry. 2002;159(11):1889-95 Misri S et al. Am J Psychiatry. 2006; 163(6):1026-32 Oberlander TF et al. Arch Pediatr Adolesc Med. 2007; 161(1):22-9

19

2011 Controversy: SSRIs and Autism • Association found between RX written for SSRIs (mom) and a DX code for autism spectrum disorder (child) • Findings not statistically significant when adjusted for estimated maternal mental illness – except for first trimester exposure (AOR 3.5, 95% CI 1.57.9)

• Did not show analysis excluding families without an autistic sibling • Did not control for paternal mental illness, tobacco, alcohol, or illicit substance use.

• Did not confirm SSRI exposure Croen LA et al. Arch Gen Psychiatry. 2011; 68(11):1104-12

20

Stopping or reducing SSRIs in third trimester has not been properly studied and increases risk of relapseâ&#x20AC;Ś.

1. Hostetter A et al. Depress Anxiety. 2000; 11(2):51-7. 2. Miller LJ et al. J Clin Psychiatry. 2008;69(2):323-4. 3. Sit DK et al. J Clin Psychiatry. 2008; 69:652-8

21

In factâ&#x20AC;Ś. dosage increase may be necessary during pregnancy

22

Medication Dosing

Sit DK et al. J Clin Psychiatry. 2008; 69:652-8

23

But it is not quite so simpleâ&#x20AC;Ś..

24

Fluoxetine: racemic levels decrease...

Mean Dose-Corrected Racemic Levels (Level to Dose=L/D Ratio) Across Childbearing Weeks

Sit DK et al. J Clin Psychopharmacol. 2010; 30(4):381-6

25

Butâ&#x20AC;ŚS-norfluoxetine levels increase

Mean Chiral Dose-Corrected Levels (Level/Dose=L/D Ratio) Across Childbearing Weeks

Sit DK et al. J Clin Psychopharmacol. 2010; 30(4):381-6

26

Benzodiazepines • Majority of studies found no increased risk of major malformations including oral cleft • Clonazepam and lorazepam preferred over diazepam and alprazolam (intermediate half-life) • Limited long term studies show no adverse effects for pregnancy or lactation • Monitor baby for transient neonatal complications Ornoy A et al. Reprod Toxicology. 1998; 12(5):511-5 Eros E et al. Eur J Obst Gynecol Reprod Biol. 2002; 101(2):147-54 Almgren M et al. Seizure. 2009; 18(10):672-5 Misri S et al. Can J Psychiatry. 2004; 49(10):684-9 Kjaer D et al. Pharmacoepidemiol Drug Saf. 2007; 16(2):181-8

27

Non-Benzodiazepine Hypnotics • Zolpidem – Limited human data in pregnancy and lactation • no increase in malformations • low risk of neonatal complications

• Zopiclone and Eszopiclone – Minimal data in pregnancy and lactation for zopiclone Juric S et al. Arch Womens Ment Health. 2009; 12(6):441-6 Wang LH et al. Clin Pharmacol Ther. 2010; 88(3):369-74 Diav-Citrin O et al. Am J Perinatol. 1999; 16(4):157-60 Stephens S et al. Reprod Toxicol. 2008; 26:73-4 Mathieu OMF et al. Fundam Clin Pharmacol. 2010; 24(Suppl. 1):424

28

Breastfeeding: Management Principals • Breast is best only if mom will be ok • Exposure in pregnancy is higher – do not switch postpartum

• Risk of relapse is very serious – do not stop medication

29

Medications in Lactation • Side effects are rare • Antidepressants – Sertraline considered first line due to low transfer • Benzodiazepines – use cautiously (lorazepam, clonazepam preferred)

Misri S & Kendrick K. Can J Psychiatry. 2007; 52(8):489-98 Davis MF et al. J Clin Psychiatry. 2009; 70(2):297-8

30

Summary • There is no such thing as non-exposure • Evidence-based medicine guides the choice of the medications with the – Best efficacy for the individual patient – Best reproductive safety data • The “standard of care” is evolving

31

Anxiety Disorders in Pregnancy & Postpartum Dr. Diana Carter Clinical Associate Professor, Psychiatry University of British Columbia Psychiatrist, Reproductive Mental Health Program Vancouver, Canada

1

Disclosure Information

â&#x20AC;˘ Grants: Wyeth, Lundbeck, Pfizer

2

Introduction Most anxiety disorders are chronic relapsing conditions with acute exacerbation  Perinatal period generally acts as a trigger  May occur independently or comorbidly with other psychiatric disorders such as major depression of bipolar mood disorder 

3

Effects on Fetus of Maternal Anxiety Disorders  





Over-activity of maternal endocrine system Exposure of fetus to cortisol  premature labour and delivery, lower birth weight, shorter birth length, shortened gestational age Release of catecholamines  maternal vasoconstriction  limitation of oxygen and nutrients to fetus Increased levels of adrenal hormones  consequences for fetal CNS: specifically glucocorticoids on brain receptor development

Sandman CA et al. Ann N Y Acad Sci. 1994;739:198-210.

Wadhwa PD et al. Am J Obstet Gynecol. 1993;169:858-65 Monk C et al. Dev Psychobiol. 2000;36:67-77 Hosseini SM et al. Paediatr Perinat Epidemiol. 2009;23:557-66.

4

Effects of Antenatal Anxiety on the Child 





18 weeks gestation associated with behavioural/emotional problems in girls aged 4-7 years 32 weeks gestation associated with behavioural/emotional problems in boys aged 47 years 12-22 weeks gestation associated with ADHD symptoms in boys 8-9 and 14-15 years

O’Connor TG et al. Br J Psychiatry. 2002;180:502-8.

O’Connor TG et al. J Child Psychol Psychiatry. 2003;44(7):1025-36.

Van den Bergh BR & Marcoen A. Child Dev. 2004;75(4):1085-97.

Van den Bergh BR et al. Neurosci Biobehav Rev. 2005;29(2):259-69.

Van den Bergh BR et al. Pediatr Res. 2006;59(1):78-82.

5

Perinatal Panic Disorder

6

Prevalence Prevalence (DSM-IV): 1.3 to 2%  Lifetime prevalence: 1.5 to 3%  Prevalence in perinatal period:1.3-3.2%  50% of individuals have comorbid depression 

Wenzel A et al. J Anxiety Disord. 2005; 19:295-311 Melville JL et al. Obstet Gynecol. 2010; 116(5):1064-70

7

Panic Disorder: Infant and Maternal Outcomes 





Increased risk of alcohol use in pregnancy compared to women without panic disorder1 Population-based, case-control studies show:  increased risk of preterm birth2,3  ± Increased risk of small for gestational age2,3 Increased risk for Postpartum Depression4,5 Meshberg-Cohen S et al. Compr Psychiatry. 2007;48(6):504-10 Chen YH et al. J Affect Disord. 2009; 119(1-3):172-6.

Banhidy F et al. Eur J Obstet Gynecol Reprod Biol. 2006; 124:47-52 Rambelli C et al. J Affect Disord. 2010; 122(1-2):139-43.

Sutter-Dallay AL et al. Eur Psychiatry. 2004;19(8):459-63.

8

Presentation Symptoms similar to general population  Nocturnal episodes common  Peak within 10 minutes but may last several hours  Dx in 3rd trimester is often overlooked  In postpartum – may be associated with weaning 

Northcott CJ & Stein MB. J Clin Psychiatry. 1994;55:539-42 Guler O et al. Compr Psychiatry. 2008; 49(2):154-8

9

New Onset and Course   



New onset may occur in pregnancy or postpartum (first 12 weeks high risk) Prenatal panic disorder predicts postnatal panic disorder and postpartum depression Studies report no change, improvement or worsening in pregnancy but usually worsening postpartum Pre-pregnancy diagnosis is the best predictor of the occurrence of perinatal panic disorder Sholomoskas DE et al. J Clin Psychiatry. 1993;54:476-80.

Cowley DS et al. J Psychosom Obstet Gynecol. 1989;10:193-210.

Hertzberg T et al. J Psychosom Obstet Gynecol. 1999;20(2):59-64.

Heron J et al. J Affect Disord. 2004;80(1):65-73

10

Differential Diagnosis Thyroid dysfunction  Anemia  Pre-eclampsia  Pheochromocytoma  Substance intoxication or withdrawal 

American Psychiatric Association Practice Guideline for the Treatment of Panic Disorder, 2nd Edition. Washington, DC: American Psychiatric Association; 2009.

Simon NM et al. J Affect Disord. 2002;69(1-3):209-17.

Kent GN et al. Clin Endocrinol. 1999;51(4):429-38.

Banhidy F et al. Eur J Obstet Gynecol Reprod Biol. 2006; 124:47-52 Kondziella D et al. J Neurol. 2007;254:1612-3.

11

Treatment 

Self care strategies: Diet - Eliminate caffeine, Regular meals  Exercise  Attend to sleep  Relaxation techniques 

SSRI’s, anxiolytics & antipsychotics  CBT  Combining CBT & meds 

Ham P et al. Am Fam Physicians. 2005;71:733-40

12

Perinatal Obsessive Compulsive Disorder

13

Prevalence Prevalence of OCD in pregnancy: .2% to 1.2%  Prevalence of OCD in postpartum: 2.7 to 9%  New onset in postpartum: 2.3%  Lifetime prevalence (DSM-IV): 2.5% 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association: 1994 Zambaldi CF et al. Compr Psychiatry. 2009;50:503-9

14

Onset and Course     

40% of childbearing OCD have onset in pregnancy 30% of childbearing OCD have onset in postpartum Some women experience increase of symptoms Others report no change Debilitating illness

Neziroglu F et al. Am J Psychiatry. 1992;149:947-950.

Williams KE & Koran LM. J Clin Psychiatry. 1997;58:330-4.

Buttolph L & Holland A. In: Jenike M, Baer L, Minichiello WE, eds. Obsessive-compulsive Disorder: Theory and Management. Chicago, Ill: Yearbook Medical Publishers; 1990:89-95.

Labad J et al. J Clin Psychiatry. 2005;66:428-35.

15

Presentation Obsessional thoughts experienced by 3465% of new parents  Fears of intentionally or accidentally harming fetus/child  Over 40% of women with PPD experience obsessional thoughts 

Wisner KL et al. J Clin Psychiatry. 1999:60:176-80 Abramowitz JS et al. J Clin Psychol Med Settings. 2003;10:157-64.

Abramowitz JS et al. J Anxiety Disord. 2003;17:461-478

16

Difference Between 1° Obsessions and Psychosis 

OCD thoughts: ego-dystonic  Sufferers go to great lengths to avoid acting on them 



Psychosis: ego-syntonic  May act on them if untreated 

Abramowitz JS et al. J Anxiety Disord. 2003;17:461-78 Terp IM, Mortensen PB. Br J Psychiatry. 1998;172:521-6.

Spinelli MG. Am J Psychiatry. 2004;161:1548-57.

17

Compulsive Behaviors Checking & rechecking  Washing  Cleaning  Counting  Rituals during baby care i.e., diaper change, bath, feeding, etc. 

Arnold LM. Prim Care Companion J Clin Psychiatry. 1999;1:103-8 Jennings KD et al. J Affect Disord. 1999;54:21-28 Sichel DA et al. J Clin Psychiatry. 1993;54:156-159 Brockington I. Lancet. 2004;363:303-310

18

Effects on Infant Infant-focused OCD impacts mother/baby relationship  Inability or refusal to leave newborn, avoidance, fear of separation  Fear of being alone with infant  Psychiatric/learning disorders in children associated with impaired maternal behaviour 

Arnold LM. Prim Care Companion J Clin Psychiatry. 1999;1:103-8 Jennings KD et al. J Affect Disord. 1999;54:21-8 Sichel DA et al. J Clin Psychiatry. 1993;54:156-9 Brockington I. Lancet. 2004;363:303-10

19

Treatment Cognitive Behavioural Therapy (CBT)  SSRI’s  Augmenting SSRI’s with Quetiapine & other antipsychotics  CBT combined with pharmacotherapy  Preventive intervention during pregnancy may lessen postpartum risk 

Arnold LM. Prim Care Companion J Clin Psychiatry. 1999;1:103-8 Sichel DA et al. J Clin Psychiatry. 1993;54:156-9 Chelmow D & Halfin VP. J Matern Fetal Med. 1997;6:31-4 Misri S & Milis L. J Clin Psychopharmacol. 2004;24:624-7 Timpano K et al. J Psychiatr Res. 2011; 45(11):1511-7

20

Perinatal Posttraumatic Stress Disorder

21

Prevalence In community based population (DSM-IV): 1 to 14%  Prevalence in perinatal women: 0% to 6.9% (higher in women following pregnancy loss)  Wide range of prevalence due to absence of differentiation between clinical PTSD vs.

PTSD symptoms 

Loveland Cook CA et al. Obstet Gynecol. 2004;103(4):710-7 Soderquist J et al. J Anxiety Disord. 2004;18(2):127-142 Shalev AY et al. Br J Clin Psychol. 1993;32:247-53

22

Presentation/Predictors Severe dysfunction  Avoidance of the baby  Impaired mother/infant bonding  Avoidance of future childbearing  Request for C-section, termination, or sterilization 

Fones C. J Nerv Ment Dis. 1996;184:195-6 Ryding EL. Acta Obstet Gynecol Scand. 1993;72:280-285 Ryding EL et al. Acta Obstet Gynecol Scand. 1997;76:856-861 Goldbeck-Wood S. BMJ. 1996;313(7060):774

23

Risk Factors Childhood sexual abuse  Instrumental deliveries, C-section, medical procedures  Perceived lack of support from hospital staff  Trauma  Partner related violence  Immigration 

Loveland Cook CA et al. Obstet Gynecol. 2004;103(4):710-7 Harris-Britt A et al. J Clin Psychol Med Settings. 2004;11:253-64 Matthey S. Stress Med. 1999;15:103-7 Soderquist J et al. J Psychosom Obstet Gynaecol. 2002;23:31-39

24

Treatment 

CBT approach to PTSD Understand link between trauma and current experience  Identify feelings and thoughts  Develop coping plans for recovery 

Treat comorbid psychiatric conditions  Pharmacotherapy where needed 

Beck CT. Nurs Res. 2004;53:216-24 Allen S. J Reprod Infant Psychol. 1998;16:107-31 Gamble J et al. Birth. 2005;32(1):11-9

25

Generalized Anxiety Disorder

26

Prevalence General population: 3 to 5%  Pregnancy: 8.5%  Postpartum: 4.4 to 8.5 %  Higher rate of GAD in perinatal compared to general population 

Wenzel A et al. J Anxiety Disord. 2005;19(3):295-311 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association: 1994 Ballard C et al. Eur J Psychiatry. 1993;7:117-21 Carter AS et al. J Am Acad Child Adolesc Psychiatry. 2001;40(1):18-26

27

Presentation/Predictors Difficult to differentiate from normal, nonpathological anxiety  Can occur without any identifiable trigger  Widespread – to multiple domains of person’s life  Interferes with daily functioning 

EXCESSIVE WORRY American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association: 1994 Ross LE et al. Arch Women Ment Health. 2003;6:51-7

28

Worry Themes Harm to baby  Harm to loved ones  Finances  Cleanliness  Disasters  Work related 

Brockington IF et al. Arch Womens Ment Health. 2006;9:253-63 Uguz F et al. J Clin Psychiatry. 2007;68:132-8.

Zambaldi CF et al. Compr Psychiatry. 2009;50:503-9

29

Onset/Comorbidity Subsyndromal worry prior to pregnancy/childbirth  History of clinical GAD  Often associated with OCD and Depression 

Wenzel A et al. Arch Women Ment Health. 2003;6(1):43-9

30

Treatment High doses of antidepressants  Augmentation with antipsychotic in severe cases  Ongoing psychoeducation with patient and their family members  Cognitive Behavioural Therapy 

Abramowitz JS. J Consult Clin Psychol. 1997; 65:44-52 Brandes M et al. Arch Womens Ment Health. 2004;7:99-110

31

Summary Perinatal anxiety disorders are debilitating and impact negatively on the mother infant dyad  There is high comorbidity with postpartum depression  Treat as soon as possible 

32

Bipolar Disorder in Pregnancy and Postpartum Dr. Shaila Misri Founding Director of the Reproductive Mental Health Program, B.C. Womenâ&#x20AC;&#x2122;s Hospital, Vancouver, B.C., Canada Director of Research & Continuing Medical Education Clinical Professor, Psychiatry & Ob/Gyn University of British Columbia APA 2012

1

Disclosure Information Speaker Bureau Consultant

Research

Astra Zeneca

Astra Zeneca

Astra Zeneca

Lundbeck

Lundbeck

Lundbeck

Pfizer

Pfizer

Pfizer

CIHR MSFHR

Medications discussed in this presentation are off label.

2

Objectives 1. To understand the presentation and course of bipolar disorder spectrum in pregnancy and the postpartum.

2. To understand the perinatal risk factors in bipolar disorder.

3. To understand the principles of treatment for this patient group.

3

A Time of Joy?

4

Bipolar Spectrum Disorder 

Types of presentation: 1) BD I 2) BD II



Chronic relapsing course

Phelps J et al: Bipolar Disord. 2008; 10:179-93 Sharma V et al. J Affect Disord. 2010; 125:18-26

5

Assessment 



No screening tools exist for BD I & II CANMAT & ISBD recommend universal screening during pregnancy & postpartum

Yatham LN et al. Bipolar Disord. 2009; 11:225-55 Sharma V et al. J Affect Disord. 2010; 125:18-26 Sharma V & Penava D. J Obstet Gynaecol Can 2010; 32:278-81

6

Diagnosis of BD I & II 

 



BD I: Mild hypomania often missed post birth BD II: Underdiagnosed & undertreated Comorbidity: Substance use, anxiety disorders, personality disorders Treatment often delayed American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorder. 4th ed. Washington, D.C., APA, 1994 Sharma V et al. J Affect Disord. 2010; 125:18-26; Ghaemi SN et al. J Psychiatr Pract. 2001; 7:287-97 Viguera et al. Am J Psych. 2007; 164:1817-24; MacQueen GM & Young LT. Psychiatr Serv. 2001; 52:358-61 Kelly E & Sharma V. Expert Rev Neurother. 2010; 10(7):1045-51.

7

Risk Factors

8

Genetic Risk Factors 



74% develop psychosis if 1st degree relative has hx of postpartum psychosis Prior hx of BD: 100 fold risk of postpartum psychosis



Risk of BD ↑ 14 fold if parent has BD I



Risk of BD by 50-60% w/ subsequent pregnancies

Sharma S & Khan M. J Obstet Gynaecol Can. 2010; 32:1028; Jones I & Craddock N. Am J Psychiatry 2001; 158:913-7 Yonkers KA et al. Obstet Gynecol 2011; 117:961-77; Birmaher B et al. Arch Gen Psychiatry 2009; 66:287-96; Freeman MP et al. J Clin Psychiatry. 2002; 63(4):284-7

9

Psychosocial Risk Factors for BD

Absence of Social Supports

Poor Marital Relationship

Sleep Loss

Sharma V & Mazmanian D. Bipolar Disord. 2003; 5:98-105; Ross LE et al. J Psychiatry Neurosci. 2004; 30:247-56 Boyce P & Hickey A. Soc Psychiatry Psychiatr Epidemiol. 2005; 40:605-12; Pfuhlmann B et al. Curr Psychiatry Rep. 2002; 4:185-90 Bilszta JLC et al. Bipolar Disord. 2010; 12:568-78; Danaci et al. Soc Psychiatry Pscyhiatr Epidemiol. 2002; 37:125-9.

10

BD I Presentation 

Pregnancy does not have a protective effect



20-30% with BD I develop psychosis



1-2/ 1000 deliveries develop postpartum psychosis (BD I until proven otherwise)

Freeman MP et al. J Clin Psychiatry. 2002; 63(4):284-7; Viguera AC et al. Am J Psychiatry. 2000; 157:179-84 Yonkers KA et al. Am J Psychiatry. 2004; 161:608-20; Kelly E & Sharma V. Expert Rev Neurother. 2010; 10(7): 1045-51 Cohen LS. J Clin Psychiatry. 2007; 68(Suppl 9):4-9.

11

12

Suicide 





Leading cause of maternal deaths in pregnancy & postpartum (1 yr) Maternal suicide rate similar to general female population rate  3/100,000 vs. 3.4/100,000 Following postpartum psychiatric admission  Risk is 70 times higher in first year postpartum

Appleby L et al. Br J Psychiatry. 1998; 173:209-11 Oates M. Br J Psychiatry. 2003; 183:279-81

13

Infanticide  

Exact rate of infanticide is unknown Among women admitted for postpartum psychosis: – Infant mortality was 3% (47/1567) – Most infant deaths preceded admission

Appleby L et al. Br J Psychiatry. 1998; 173:209-11; Oates M. Br J Psychiatry. 2003; 183:279-81; Spinelli M. Am J Psychiatry. 2004; 161:1548-57 Spinelli M: Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill. Washington, DC, Am Psychiatric Publishing, 2003

14

General Principles of Treatment in Pregnancy & Lactation 



Interdisciplinary care Management guided by severity (hospitalization)



Involve family and other support



Breast is best but not at mother/ baby welfare

15

Pharmacotherapy of Bipolar Spectrum Disorder

16

Specifics of BD I & II Tx & Switching Phenomenon 





BD I: Antidepressant maintenance tx for BD I is controversial BD II: Adding mood stabilizers to antidepressants prevents rapid cycling Use of antidepressants may “induce” switching phenomenon

Sharma V et al. Am J Psychiatry. 2009; 166:1217-21; Sharma V et al. J Affect Disord. 2010; 125:18-26; Bond DJ et al. J Clin Psychiatry. 2008; 69:1589-601

17

Development of Fetus

UNSW Embryology: Beginnings, Growth, and Development. Accessed in December 2010 from http://embryology.med.unsw.edu.au/Medicine/BGDlab11cc.htm

18

Teratogenicity  

Background rate of birth defects: 2-4% Most organs formed in first trimester; neural tube closes by 5 weeks



Craniofacial: also affected after first trimester



Brain: All three trimesters beyond



Neurobehavioral teratogenicity Yonkers KA. J Fam Pract. 2004; Suppl:S15-20 Stowe ZN. J Clin Psychiatry. 2007; 68(Suppl9): 22-8

19

Lithium in Pregnancy 

   

Baby • Ebstein’s anomaly 1:1000 (1 in 20,000 general population) • Floppy baby syndrome Cardiac ultrasound at 16-20 weeks Dose change in 3rd trimester (GFR, plasma volume) Avoid dehydration Mother: Hypothyroidism & DI insipidus (rare)

Viguera AC et al. Am J Psychiatry. 2000; 157:179-84; Viguera AC et al. Am J Psych. 2007; 164:1817-24; Cohen LS et al. JAMA. 1994; 271(2):146-50 American Academy of Pediatrics: Committee on Drugs Transfer of drugs and other chemicals into human milk. Pediatrics. 2001; 108:776-89 Iqbal MM. Pediatr Rev. 2000; 21(2):58-66; Yonkers KA. J Fam Pract. 2004; Suppl:S15-20; Newport DJ et al. Am J Psychiatry. 2005; 162(11):2162-70 Warner JP. J Psychopharmacol. 2000; 14(1):77-80; Pinelli JM et al. Am J Obstet Gynecol. 2002;187(1):245-9; Briggs GG. Clin Obstet Gynecol. 2002; 45(1):6-21 Iqbal MM et al. J Toxicol Clin Toxicol. 2001; 39(4):381-92; Viguera AC et al. Can J Psychiatry. 2002; 47(5):426-36

20

Bipolar Relapse Rates off Lithium

Viguera AC et al. Am J Psychiatry. 2000; 157:179-84

21

Mood Stabilizers in Pregnancy

2

Viguera et al. Am J Psychiatry. 2007; 164:1817-24

22

Polarity of Recurrence

 Major depression 41%  Mixed state 38%  Hypomania 11%

Viguera et al. Am J Psychiatry. 2007; 164:1817-24

23

Carbamazepine in Pregnancy 





Cardiac & craniofacial malformations: 2-5% “Fetal Carbamazepine Syndrome”: Epicanthic folds, facial dysmorphisms, fingernail hypoplasmia Thrombocytopenia & coagulopathy Iqbal MM. Pediatr Rev. 2000; 21(2):58-66; Frey B. Eur J Pediatr. 1990; 150:136; Stahl MM et al. J Pediatr. 1997; 130:1001; Walker SP et al. BJOH. 2009;116 (6):758-67; Hunt S et al. Neurology. 2008; 71(4):272-6; Jentik J et al. BMJ. 2010; 341:c6581 Menon S. Arch Gynecol Obstet. 2008, 277:1-13; Kloos AL et al. Curr Psychiatry Rep. 2010; 12:96-103; Nulman I. BMJ. 2010; 341:c6582

24

Valproic Acid in Pregnancy New FDA Warning: Increased risk of neural tube, craniofacial defects, cardiovascular malformations

  

 

Risk of major anomalies: 10% (monotherapy) Risk increases w/ polytherapy (16.78%) Valproate syndrome (tall forehead, epicanthic folds, flat nasal bridge) Learning disabilities & developmental delays Menstrual irregularities and polycystic ovary

Meador KJ et al. Epilepsy Res. 2008; 81(1):1-13; Omtzigt JG et al. Eur J Clin Pharmacol. 1992; 43(4):381-8 Menon S. Arch Gynecol Obstet. 2008, 277:1-13; Yonkers KA. J Fam Pract. 2004; Suppl:S15-20; Kloos AL et al. Curr Psychiatry Rep. 2010; 12:96-103 Joffe H et al. Biol Psychiatry. 2006; 59(11):1078-86; Holmes LB. Am J Med Genet. 2002; 112(3):297-303; Meador KJ et al. Neurology. 2006; 67(3):407-12 Food and Drug Administration (FDA) – U.S. Department of Health and Human Services: Valproate sodium and related products (valproic acid and divalproex sodium): Risk of birth defects. Accessed on 12/03/2009 from www.fda.gov

25

Lamotrigine in Pregnancy 

Monotherapy recommended vs. polytherapy



Orofacial clefts: 2.9% - absolute risk very low





Clearance increased by hormonal contraceptives and by pregnancy Folic acid supplementation (4-5mg/day)

Dolk H et al. Neurology. 2008;71:714-22; Cunnington M et al. Epilepsia. 2007; 48:1207-10 Meador KJ et al. NEJM. 2009; 360(16):1597-605; Walker SP et al. BJOG. 2009;116 (6):758-67; Einarson A. Motherisk statement on lamotrigine. The Motherisk Program,The Hospital for Sick Children, Toronto Canada. Per email communication Oct 8, 2009.

26

Topiramate & Gabapentin in Pregnancy 



Topiramate: • FDA warning (April 2011): Increase of oral clefts (1.4%) • Data is sparse Gabapentin: Case reports

U.S. Food and Drug Administration: Risk of oral clefts in infants born to mothers using topimax. U.S Department of Health and Human Services, c2011, Accessed from http://www.fda.gov/Drugs/DrugSafety/ucm245470.htm

27

Typical Antipsychotics in Pregnancy 

Neurobehavioral changes in animals



No long-term sequelae in humans



Hyperprolactinemia and infertility



High potency less teratogenic than lowpotency

American Academy of Pediatrics: Committee on Drugs Transfer of drugs and other chemicals into human milk. Pediatrics. 2001; 108:776-89 Altshuler L et al. Am J Psychiatry. 1996; 153:592-606; Cohen LS et al. J Clin Psychiatry. 1998; 59(Suppl 2):18-28 Patton SW et al. Can J Psychiatry. 2002; 47:959

28

Atypical Antipsychotics in Pregnancy 



Risperidone, quetiapine, olanzapine, clozapine: no congenital malformations Ziprasidone & aripiprazole: case reports

Stoner SC. J Clin Psychiatry. 1997; 58:364; Dickson RA & Dawson DT. Can J Psychiatry. 1998; 43:196; Goldstein DJ et al. J Clin Psychopharmacol. 2000; 20:399; McKenna K et al. Vet Hum Toxicol. 2004; 46:44-6; Ratnayake T et al. J Clin Psychiatry. 2002; 63:76; Taylor TM et al. Am J Psychiatry. 2003; 160:588-9.

29

Placental Transfer of Antipsychotics

Newport DJ et al. Am J Psychiatry. 2007; 164(8):1214-20

30

Lactation

31

Lithium & Lamotrigine in Lactation 



Lithium: Breast milk concentration • “Rule of halves:” Breast milk is ½ of maternal serum, and infant serum is ½ of breast milk, and ¼ of maternal level Lamotrigine: High infant serum levels: 30% (range 18-50%) of maternal levels Breastfed infant to be monitored closely

Yonkers KA. J Fam Pract. 2004; Suppl:S15-20; Frey B. Eur J Pediatr. 1990; 150:136 Page-Sharp M et al. Ann Pharmacother. 2006; 40(7-8):1470-1; Briggs GG. Clin Obstet Gynecol. 2002; 45(1):6-21; Stahl MM et al. J Pediatr. 1997; 130:1001 Merlob P et al. Ann Pharmacother. 1992; 26(12):1563-5; Newport DJ et al. Am J Psychiatry. 2005; 162(11):2162-70; Nordmo E et al. Annals of Pharmac. 2009; 43:1893-7; Ohman I et al. Epilepsia. 2000; 41:709; Harden CL et al. Neurology. 2009; 73:133-41; Tomson T et al. 1997; 38(9):1039-41; Rambeck B et al. Eur J Clin Pharmacol. 1997; 51(6):481-4; Viguera et al. Am J Psych. 2007; 164:1817-24; American Academy of Pediatrics: Committee on Drugs Transfer of drugs and other chemicals into human milk. Pediatrics. 2001; 108:776-89.

32

Carbamazepine, Valproic Acid & Other Mood Stabilizers in Lactation ď Ž

ď Ž

Carbamazepine & valproic acid: Not contraindicated by AAP No data on gabapentin & topiramate in lactation

Merlob P et al. Ann Pharmacother. 1992; 26(12):1563-5; Ohman I et al. Epilepsia. 2000; 41:709; Page-Sharp M et al. Ann Pharmacother. 2006; 40(7-8):1470-1; Stahl MM et al. J Pediatr. 1997; 130:1001 Rambeck B et al. Eur J Clin Pharmacol. 1997; 51(6):481-4; Tomson T et al. Epilepsia. 1997; 38(9):1039-41 Frey B. Eur J Pediatr. 1990; 150:136; Walker SP et al. BJOH. 2009;116 (6):758-67; Meador KJ et al. NEJM. 360(16): 1597-605; American Academy of Pediatrics: Committee on Drugs Transfer of drugs and other chemicals into human milk. Pediatrics. 2001; 108:776-89 Organization of Teratology Information Specialists (OTIS): Carbamazepine (tegretol) and pregnancy. Accessed in May 2009 from www.OTISpregnancy.org

33

Antipsychotics in Breastfeeding 

Typicals

– Reports of toxicity/ developmental delays



Atypicals:

– Quetiapine: No neurodevelopmental delays in children followed up to 3 years; low transfer – Risperidone & olanzapine: No toxicity in case reports – Clozapine: High accumulation in breast milk; report of infant seizure



Ziprasidone, aripiprazole: No data

Ilett KF et al. Ann Pharmacother. 2004; 38(2):273-6; Hill RC et al. J Clin Psychopharmacol. 2000; 20(2):285-6 Croke S et al. Int J Neuropsychopharmacol. 2002; 5(3):243-7; Lee A et al. Am J Psychiatry. 2004; 161(9):1715-6 Misri SM et al. J Clin Pharmacol. 2006; 26(5):508-51; Misri SM et al. Can J Psychiatry. 2004; 49(10):684-9; Yoshida K et al. Psychol Med. 1998; 28(1):81-91 Goldstein DJ et al. J Clin Psychopharmacol. 2000; 20:399; Patton SW et al. Can J Psychiatry. 2002; 47:959; Barnas C et al. Am J Psychiatry. 1994; 151(6):945

34

ECT in Pregnancy 

Not teratogenic



Complications infrequent and transient



No long-term follow-up studies available



Safe and effective with modifications in technique

Yonkers KA. J Fam Pract. 2004; Suppl:S15-20; Miller LJ. Hosp Community Psychiatry. 1994; 45(5):444-50; Pinette MG et al. Obstet Gynecol. 1997; 110(2 Part 2):465-6

35

Bottom Line

Donâ&#x20AC;&#x2122;t wait. Treat!

36

At the End of the Day

37

Background Articles The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s).

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Background Articles Appleby L, Mortensen PB, Faragher EB: Suicide and other causes of mortality after post-partum psychiatric admission. The British Journal of Psychiatry 1998; 173:209-211.

Altshuler LL, Hendrick V, Cohen LS: Course of mood and anxiety disorders during pregnancy and the postpartum period. J Clin Psychiatry 1998; 59(Suppl 2):29-33.

Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR: Prevalence of depression during pregnancy: a systematic review. Obstet Gynecol 2004; 103(4):698-709.

Brockington IF, Macdonald E, Wainscott G. Anxiety, obsessions and morbid preoccupations in pregnancy and the puerperium. Arch Womens Ment Health 2006; 9: 253-263.

Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, Suri R, Burt VK, Hendrick V, Reminick AM, Loughead A, Vitonis AF, Stowe ZN: Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006; 295(5):499-507 Freeman MP. Smith KW. Freeman SA. McElroy SL. Kmetz GE. Wright R. Keck PE Jr: The impact of reproductive events on the course of bipolar disorder in women. J Clin Psychiatry 2002; 63(4):284-7.

Hosseini SM, Biglan MW, Larkby C, Brooks MM, Gorin MB, Day NL: Trait anxiety in pregnant women predicts offspring birth outcomes. Paediatr Perinat Epidemiol 2009;23:557-566.

Misri S, Kendrick K. Treatment of perinatal mood and anxiety disorders: a review.

Can J Psychiatry. 2007 Aug;52(8):489-98.

Uguz F, Akman C, Kaya N, Cilli AS. Postpartum-onset obsessive-compulsive disorder: incidence, clinical features, and related factors. J Clin Psychiatry 2007; 68: 132-8.

Viguera AC, Cohen L, Baldessarini RJ, Nonac R: Managing Bipolar Disorder During Pregnancy: Weighing the Risks and Benefits. Can J Psychiatry 2002; 47(5): 426-436.

Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, Ramin S, Chaudron L, Lockwood C: The management of depression during pregnancy:

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstetrics Gynecology 2009; 114(3):703-713.

Yonkers KA, Wisner KL, Stowe Z, Leibenluft E, Cohen L, Miller L, Manber R, Viguera A, Suppes T, Altshuler L: Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004; 161:608-620.

References The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s).

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

References- Dr. Deirdre Ryan Altshuler LL, Hendrick V, Cohen LS: Course of mood and anxiety disorders during pregnancy and the postpartum period. J Clin Psychiatry 1998; 59(Suppl 2):29-33.

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Appleby L: Suicide during pregnancy and in the first postnatal year. BMJ 1991; 302:137-40.

Austin MP: Antenatal screening and early intervention for “perinatal” distress, depression and anxiety: where to from here? Arch Womens Ment Health 2003; 7:1-6.

Avan B, Richter LM, Ramchandani PG, Norris SA, Stein A: Maternal postnatal depression and children’s growth and behavior during the early years of life: exploring the interaction between physical and mental health. Arch Dis Child 2010; 95:690-5.

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Beck CT: Predictors of postpartum depression: an update. Nurs Res 2001; 50:275-85.

Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR: Prevalence of depression during pregnancy: a systematic review. Obstet Gynecol 2004; 103(4):698-709.

Brand SR & Brennan PA: Impact of antenatal and postpartum maternal mental illness: how are the children? Clin Obstet Gynecol 2009;52(3):441-55.

Brennan PA, Pargas R, Walker EF, Green P, Newport DJ, Stowe Z: Maternal depression and infant cortisol: influences of timing, comorbidity and treatment. J Child Psychol Psychiatry 2008;49(10):1099-107.

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Clark R, Tluczek A, Wenzel A: Psychotherapy for postpartum depression: a Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 preliminary report. Am J Orthopsychiatry 2003; 73(4):441-54.

Cohen LS: Pharmacologic treatment of depression in women: PMS, pregnancy, and the postpartum period. Depress Anxiety 1998; 8(1):18-26.

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Einarson A, Fatoye B, Sarkar M, Lavigne SV, Brochu J, Chambers C, Mastroiacovo P, Addis A, Matsui D, Schuler L, Einarson TR, Koren G: Pregnancy outcome following gestational exposure to venlafaxine: a multicenter prospective controlled study. Am J Psychiatry 2001; 158(10):1728-30.

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Field T, Diego M, Hernandex-Reif M, Deeds O, Figueiredo B: Pregnancy massage reduces prematurity, low birthweight and postpartum depression. Infant Behav Dev 2009; 32(4):454-60.

Field T, Diego M, Hernandez-Reif M: Depressed mothersâ&#x20AC;&#x2122; infants are less responsive to faces and voices. Infant Behav Dev 2009; 32(3):239-44.

Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T: Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 2005; 106:1071-83.

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC: Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ). 2005; 119:1-8.

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Grote NK, Bledsoe SE, Swartz HA, Frank E: Feasibility of Providing Culturally Relevant, Brief Interpersonal Psychotherapy for Antenatal Depression in an Obstetrics Clinic: A Pilot Study. Res Soc Work Pract 2004; 14:397-407.

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Holden JM: Postnatal depression: its nature, effects, and identification using the Edinburgh Postnatal Depression scale. Birth 1991; 18(4):211-21.

Honey KL, Bennett P, Morgan M: A brief psycho-educational group intervention for postnatal depression. Br J Clin Psychol 2002; 41:405-9.

Hostetter AL & Stowe ZN: Postpartum Mood disorders. Identification and treatment. In: Lewis-Hall F, Williams TS, Panetta JA, Herrera JM, editors.

Psychiatric illness in women. Emerging treatments and research. Washington (DC): American Psychiatric Publishing Inc., 2002. p. 133-56.

Jacobsen T, Hibbs E, Ziegenhain U: Maternal expressed emotion related to attachment disorganization in early childhood: a preliminary report. J Child Psychol Psychiatry, 2000; 41(7):899-906.

Josefsson A, Berg G, Nordin C, Sydsjo G: Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstet Gynecol Scand 2001; 80(3):251-55.

Kim P, Swain JE: Sad dads: paternal postpartum depression. Psychiatry (Edgmont) 2007; 4(2):35-47.

Klier CM, Muzik M, Rosenblum KL, Lenz G: Interpersonal psychotherapy adapted for the group setting in the treatment of postpartum depression. J Psychother Pract Res 2001;10(2):124-31.

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Kozhimannil KB, Pereira MA, Harlow BL: Association between diabetes and perinatal depression among low-income mothers. JAMA 2009; 301(8):842-7.

Lindahl V, Pearson JL, Colpe L: Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health 2005; 8(2):77-87.

Magiakou MA, Mastorakas G, Rabin D, Dubber B, Gold PW, Chrouses GP: Hypothalamic corticotrophin-releasing hormone suppression during the postpartum period: implications for the increase of psychiatric manifestations at this time. J Clin Endocrinol 1996; 81:1912-17.

Manber R, Schnyer RN, Lyell D, Chambers AS, Caughey AB, Druzin M, Carlyle E, Celio C, Gress JL, Huang MI, Kalista T, Martin-Okada R, Allen JJ: Acupuncture for depression during pregnancy: a randomized controlled trial.

Obstet Gynecol 2010; 115(3):511-20.

Marcus SM, Flynn HA, Blow FC, Barry KL: Depressive symptoms among pregnant women screened in obstetric settings. J Womens Health 2003; 12 (4):373-80.

Meager I, Milgrom J: Group treatment for postpartum depression: a pilot study.

Aust N Z J Psychiatry. 1996; 30(6):852-60.

Melrose, S: Paternal postpartum depression: how can nurses begin to help?

Contemp Nurse 2010; 34(2):199-210.

Meltzer-Brody S: New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011; 13(1):89-100.

Misri S, Reebye P, Kendrick K, Carter D, Ryan D, Grunau RE, Oberlander TF: Internalizing behaviors in 4-year-old children exposed in utero to psychotropic medications. Am J Psychiatry 2006; 163(3):1026-32.

Morgan M, Matthey S, Barnett B, Richardson C: A group programme for postnatally distressed women and their partners. J Adv Nurs 1997; 26(5):913-20.

Moses-Kolko EL, Berga SL, Kalro B, Sit DKY, Wisner K: Transdermal estradiol for postpartum depression: a promising treatment option. Clin Obstetr Gynecol 2009; 52(3): 516-29.

Mulcahy R, Reay RE, Wilkinson RB, Owen C: A randomised control trial for the effectiveness of group interpersonal psychotherapy for postnatal depression.

Arch Womens Ment Health 2010; 13(2): 125-39.

Murray L, Cooper P: Effects of postnatal depression on infant development. Arch Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Dis Child 1997; 77(2):99-101.

Murray L, Cooper PJ, Wilson A, Romaniuk H: Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child relationship and child outcome. Br J Psychiatry 2003; 182:420-7.

National Institute of Mental Health. Mental disorders in America. Available at: www.nimh.nih.gov/publicat/numbers/cfm Accessed August 25, 2004 Ng RC, Hirata CK, Yeung W, Haller E, Finley PR: Pharmacologic treatment for postpartum depression: a systematic review. Pharmacotherapy 2010; 30(9):927941.

Oberlander TF, Papsdorf M, Brain UM, Misri S, Ross C, Grunau RE: Prenatal effects of selective serotonin reuptake inhibitor antidepressants, serotonin transporter promoter genotype (SLC6A4), and maternal mood on child behaviour at 3 years of age. Arch Pediatr Adolesc Med 2010; 164(5):444-51.

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Paulson JF & Bazemore SD: Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA 2010; 3030(19): 1961-9.

Paulson JF, Dauber S, Leiferman JA: Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Pediatrics 2006; 118(2):659-68.

Pearlstein T, Howard M, Salisbury A, Zlotnick C: Postpartum depression. ACOG 2009; 200(4):357-64.

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Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 2004; 26(4):289-95.

Rubersston C, Wickberg B, Gustavsson P, Radestad I: Depressive symptoms in early pregnancy, two months and one y ear postpartum-prevalence and psychosocial risk factors in a national Swedish sample. Arch Womens Ment Health 2005; 8(2):97-104.

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Weissman MM, Pilowsky DJ, Wickramaratne PJ, Talati A, Wisniewski SR, Fava M, Hughes CW, Garber J, Malloy E, King CA, Cerda G, Sood AB, Alpert JE, Trivedi MH, Rush AJ: Remissions in maternal depression and child psychopathology: a STAR*D child report. JAMA 2006; 295(12):1389-98.

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Additional References: Abramowitz JS, Schwatz SA, Moore KM, Luenzmann KR: Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Anxiety Disorders 2003; 17:461-478.

Ayers S, Pickering AD: Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth 2001;28(2):111-8.

Cohen LS, Sichel DA, Dimmock JA, Rosenbaum JF: Postpartum course in women with preexisting panic disorder. J Clin Psychiatry 1994; 55(7):289-92.

Cohen LS, Sichel DA, Faraone SV, Robertson LM, Dimmock JA, Rosenbaum JF: Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Course of panic disorder during pregnancy and the puerperium: a preliminary study. Biol Psychiatry 1996; 39(11):950-4.

Cox JL, Murray D, Chapman G: A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 1993; 163:27-31.

Franko DL, Blais MA, Becker AE, Delinsky SS, Greenwood DN, Flores AT, Ekeblad ER, Eddy KT, Herzog DB: Pregnancy Complications and Neonatal Outcomes in Women With Eating Disorders. Am J Psychiatry 2001; 158:14611466.

Kim DR, Gonzales JM, Cristancho P, Wakil L, Parry S, Elovitz MA, Rickels K, Thase ME, Oâ&#x20AC;&#x2122;Reardom JP: Repetitive transcranial magnetic stimulation (rTMS) for antenatal depression. Poster presentation. APA 2009 San Francisco.

Kouba S, Hallstrom T, Lindholm C, Hirschberg AL: Pregnancy and neonatal outcomes in women with eating disorders. Obstet Gynecol 2005;105(2):255-60.

Loveland Cook CA, Flick LH, Homan SM, Campbell C, McSweeney M, Gallagher ME: Posttraumatic stress disorder in pregnancy: prevalence, risk factors, and treatment. Obstet Gynecol 2004;103(4):710-7.

Micalli N, Simonoff E, Treausre J: Risk of major adverse perinatal outcomes in women with eating disorders. Br J Psychiatry 2007; 190:255-9.

Neziroglu F, Anemone R, Yaryura-Tobias JA: Onset of obsessive-compulsive disorder in pregnancy. Am J Psychiatry 1992; 149(7):947-50.

Ross, LE, McLean LM: Anxiety Disorders During Pregnancy and the Postpartum Period: A Systematic Review. J Clin Psychiatry 2006; 67(8):1285-98.

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Chambers CD, Hernandez-Diaz S, Van Marter LJ, Werler MM, Louik C, Jones KL, Mitchell AA: Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. New Engl J Med 2006; 354(6):579-87.

Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, Suri R, Burt VK, Hendrick V, Reminick AM, Loughead A, Vitonis AF, Stowe ZN: Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006; 295(5):499-507.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Diav-Citrin O, Shechtman, S, Weinbaum D, Wajnberg R, Avgil, M, Di Gianantonio E, Clementi M, Weber-Schoendorfer D, Schaefer C, Ornoy A: Paroxetine and fluoxetine in pregnancy: a prospective, multicentre, controlled, observational study. B J Clin Pharmacol 2008; 66(5):695-705.

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Einarson A, Pistelli A, Desantis M, Malm H, Paulus WD, Panchaud A, Kennedy D, Einarson TR, Koren G: Evaluation of the risk of congenital cardiovascular defects associated with use of paroxetine during pregnancy. Am J Psychiatry 2008; 165(6):749-52.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Hostetter A, Stowe ZN, Strader JR, Jr., McLaughlin E, Llewellyn A: Dose of selective serotonin uptake inhibitors across pregnancy: clinical implications.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Maschi S, Clavenna A, Campi R, Schiavetti B, Bernat M, Bonati M: Neonatal outcome following pregnancy exposure to antidepressants: a prospective controlled cohort study. BJOG 2008;115(2):283-9.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Hennen J, Cohen LS: Birth outcomes following prenatal exposure to antidepressants. J Clin Psychiatry. 2007; 68(8):1284-9.

Pedersen LH, Henriksen TB, Vestergaard M, Olsen J, Bech BH: Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: population based cohort study. BMJ. 2009;339:b3569.

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Sit DK, Perel JM, Luther JF, Wisniewski SR, Helsel JC, Wisner KL: Disposition of chiral and racemic fluoxetine and norfluoxetine across childbearing. J Clin Psychopharmacol. 2010;30(4):381-6.

Stephens S, Wilson G, Gilfillan C, McElhatton PR, Thomas SHL: Preliminary data on therapeutic exposure to zopiclone during pregnancy. Reprod Toxicol 2008; 26:73-4.

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Toh S, Mitchell AA, Louik C, Werler MM, Chambers CD, Hernandez-Diaz S: Selective serotonin reuptake inhibitor use and risk of gestational hypertension.

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Van den Bergh BR, Mulder EJ, Mennes M, Glover V: Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child; links and possible mechanisms. A review. Neurosci Biobehav Rev 2005; 29(2):237-58.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Wilson KL, Zelig CM, Harvey JP, Cunningham BS, Dolinsky BM, Napolitano PG: Persistent pulmonary hypertension of the newborn is associated with mode of delivery and not with maternal use of selective serotonin reuptake inhibitors. Am J Perinatol 2011;28(1):19-24.

Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, Ramin S, Chaudron L, Lockwood C: The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114(3):703-13.

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Chambers CD, Polifka JE, Friedman JM. Drug safety in pregnant women and their babies: ignorance not bliss. Clin Pharmacol Ther 2008; 83(1):181-3.

Kim J, Riggs KW, Misri S, Kent N, Oberlander TF, Grunau RE, Fitzgerald C, Rurak DW: Stereoselective disposition of fluoxetine and norfluoxetine during pregnancy and breast-feeding. Br J Clin Pharmacol 2006; 61(2):155-63.

Lobo ED, Loghin C, Knadler MP, Quinlan T, Zhang L, Chappell J, Lucas R, Bergstrom RF: Pharmacokinetics of Duloxetine in Breast Milk and Plasma of Healthy Postpartum Women. Clin Pharmacokinet 2008;47(2):103-9.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Shipton D, Tappin DM, Vadiveloo T, Crossley JA, Aitken DA, Chalmers J: Reliability of self reported smoking status by pregnant women for estimating smoking prevalence: a retrospective, cross sectional study. BMJ. 2009;339:b4347.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Carter AS, Garrity-Rokous FE, Chazan-Cohen R, Little C, Briggs-Gowan MJ: Maternal depression and comorbidity: predicting early parenting, attachment security, and toddler social-emotional problems and competencies. J Am Acad Child Adolesc Psychiatry. 2001;40(1):18-26.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Oâ&#x20AC;&#x2122;Connor TG, Heron J, Golding J, Beveridge M, Glover V: Maternal antenatal anxiety and children's behavioural/emotional problems at 4 years. Report from the Avon Longitudinal Study of Parents and Children. Br J Psychiatry 2002; 80:502-8.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Soderquist J, Wijma K, Wijma B: Traumatic stress after childbirth: the role of obstetric variables. J Psychosom Obstet Gynaecol 2002; 23:31-9.

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Wenzel A, Haugen EN, Jackson LC, Brendle JR: Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord 2005; 19(3):295-311.

Wenzel A, Haugen EN, Jackson LC, Robinson K: Prevalence of generalized anxiety at eight weeks postpartum. Arch Women Ment Health 2003; 6(1):43-9.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Williams KE & Koran LM: Obsessive-compulsive disorder in pregnancy, the puerperium, and the premenstruum. J Clin Psychiatry 1997;58:330-4.

Wisner KL, Peindl KS, Gigliotti T, Hanusa BH. Obsessions and compulsions in women with postpartum depression. J Clin Psychiatry 1999; 60:176-80 Zambaldi CF, Cantilino A, Montenegro AC, Paes JA, Cesar de Albuquerque TL, Sougey EB: Postpartum obsessive-compulsive disorder: prevalence and clinical characteristics. Compr Psychiatry 2009; 50:503-9.

Additional References: Allaire AD, Moos MK, Wells SR: Complementary and alternative medicine in pregnancy: a survey of North Carolina certified nurse-midwives. Obstet Gynecol 2000; 95(1):19-23.

Appleby L, Warner R, Whitton A, Faragher B: A controlled study of fluoxetine and cognitive-behavioral counselling in the treatment of postnatal depression.

BMJ 1997; 314:932-36.

Armstrong K, Edwards H: The effectiveness of a pram walking exercise programme in reducing depressive symptomatology for postnatal women. Int J Nurs Pract 2004; 10:177-194.

Armstrong K, Edwards H: The effects of exercise and social support on mothers reporting depressive symptoms: A pilot randomized controlled trial. Int J Ment Health Nurs 2003, 12:130-138.

Austin MP, Hadzi-Pavlovic D, Priest SR, Reilly N, Wilhelm K, Saint K, Parker G: Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection? Arch Womens Ment Health 2010; 13(5):395-401.

Bastard J & Tiran D: Aromatherapy and massage for antenatal anxiety: Its effect on the fetus. Comp Ther Clin Pract 2006; 12:48-54.

Beard JL, Hendricks MK, Perez EM, Murray-Kolb, Berg A, Vernon-Feasgans L, Irlam J, Isaacs W, Sive A, Tomlinson M: Maternal Iron Deficiency Anemia Affects Postpartum Emotions and Cognition. J Nutr 2005; 135: 267-72.

Berle J, Holsten F, Aarre TF: Seasonal and sleep changes in postpartum depression. American Psychiatric Association Annual Meeting 2000, Chicago, Illinois; Abstract 83D.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Bodnar LM, Wisner KL: Nutrition and Depression: Implications for Improving Mental Health Among Childbearing-Aged Women. Biol Psychiatry 2005; 58:67985.

Brenner R, Madhusoodanan S, Pawlowska M: Efficacy of continuation treatment with hypericum perforatum in depression. J Clin Psychiatry 2002; 63(5): 455.

Browne JC, Scott KM, Silvers KM: Fish consumption in pregnancy and omega-3 status after birth are not associated with postnatal depression. J Affect Disord.

2006; 90(2-3):131-9.

Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Roge B, Mullet E: Prevention and treatment of post-partum depression: a controlled randomized study on women at risk. Psychol Med 2002: 32(6): 1039-47.

Clark R, Tluczek A, Wenzel A: Psychotherapy for postpartum Depression: A Preliminary Report. Am J Orthopsychiatry 2003; 73(4): 441-54.

Cooper PJ, Murray L, Wilson A, Romaniuk H: Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression:1. Impact on maternal mood. Br J Psychiatry 2003;182:412-19.

Corral MR, Kuan AJ, Kostaras D: Bright light therapy effective in postpartum depression. Am J Psychiatry 2000; 157(2):303-4.

Corral MR, Wardrop A, Zhang H: Seasonality of symptoms in women with postpartum depression. Arch Womens Ment Health 2007; 10: 9-13.

Corral MR, Wardrop A, Zhang H, Grewal AK, Patton S: Morning light therapy for postpartum depression. Arch Womens Ment Health 2007; 10:221-4.

Corwin EJ, Murray-Kolb LE, Beard JL: Low hemoglobin level is a risk factor for postpartum depression. J Nutr 2003; 133:4139â&#x20AC;&#x201C;42.

Da Silva JBG: Acupuncture for mild to moderate emotional complaints in pregnancy â&#x20AC;&#x201C; a prospective, quasi-randomised, controlled study. Acupunct Med 2007; 25(3): 65-71.

Da Silva JBG, Nakamura MU, Cordeiro JA, Kulay L: Acupuncture for insomnia in pregnancy: a prospective, quasi-randomized, controlled study. Acupunct Med 2005; 23(2): 47-51.

Dennis CL, Ross L: Relationship among infant sleep patterns, maternal fatigue, and development of depressive symptomatology. Birth 2005: 32(3):187-93.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Denomme J, Stark KD, Holub BJ: Directly quantitated dietary (n-3) fatty acid intakes of pregnancy Canadian women are lower than current dietary recommendations. J Nutr 2005; 135:206-11.

Einarson A, Mastroiacovo P, Arnon J, Ornoy A, Addis A, Malm M, Koren G: Attitudes and practices of physicians and naturopaths toward herbal products, including use in pregnancy and lactation. Can J Clin Pharmacol 2000; 7(1):45-9.

Epperson CN, Terman M, Terman JS, Hanusa BH, Oren DA, Peindl KS, Wisner KL: Randomised clinical trial of bright light therapy for antepartum depression: preliminary findings. J Clin Psychiatry 2004; 65(3):421-5.

Freeman MP, Helgason C, Hill A: Selected integrative medicine treatments for depression: considerations for women. J Am Med Womens Assoc 2004; 59(3): 216-24.

Freeman MP, Hibbeln JR, Wisner KL, Brumbach BH, Watchman M, Gelenberg AJ: Randomized dose-ranging pilot trial of omega-3 fatty acids for postpartum depression. Cta Psychiatr Scand 2006; 113:31-5.

Freeman MP, Hibbeln JR, Wisner KL, Davis JM, Mischoulon D, Peet M, Keck PE Jr, Marangell LB, Richardson AJ, Lake J, Stoll AL: Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry. J Clin Psychiatry 2006; 67(12):1954-67.

Field T, Diego MA, Hernandez-Reif M, Schanberg S, Kuhn C: Massage therapy effects on depressed pregnant women. J Psychosom Obstet Gynecol 2004; 25:115-22.

Forray A, Focseneanu M, Pittman B, McDougle CJ, Epperson CN: Onset and exacerbation of obsessive-compulsive disorder in pregnancy and the postpartum period. J Clin Psychiatry 2010;71(8):1061-8.

Glover V, Onozawa K, Hodgkinson A: Benefits of infant massage for mothers with postnatal depression. Semin Neonatol 2002; 7(6):495-500.

Golden RN, Gaynes BN, Ekstrom RD, Hamer RM, Jacobsen FM, Suppes T, Wisner KL, Nemeroff CB: The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry 2005; 162(4): 656-62.

Grote NK, Bledsoe, SE, Swartz HA, Frank E: Feasibility of Providing Culturally Relevant, Brief Interpersonal Psychotherapy for Antenatal Depression in an Obstetrics Clinic: A Pilot Study. Research on Social Work Practice 2004; 14: 397407.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Haas JS, Jackson RA, Fuentes-Afflick E, Stewart AL, Dean ML, Brawarsky P, Escobar GJ: Changes in the Health Status of Women During and After Pregnancy. J Gen Intern Med 2004; 20:45-51.

Hamama L, Rauch SA, Sperlich M, Defever E, Seng JS: Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy. Depress Anxiety 2010; 27(8):699-707.

Hibbeln JR: Seasfood consumption, the DHA content of mothersâ&#x20AC;&#x2122; milk and prevalence rates of postpartum depression: a cross-national, ecological analysis.

J Affect Disord 2002; 69(1-3):15-29.

Highet N, Drummond P: A comparative evaluation of community treatments for post-partum depression: implications for treatment and management practices: Aust N Z J Psychiatry 2004; 38(4):212-8.

Hiltunen P, Jokelainen J, Ebeling H, Szajnberg N, Moilanen I: Seasonal variation in postnatal depression: J Affect Disord 2004; 78(2):111-8.

Hiscock H, Wake M: Randomized controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. BMJ 2002; 324(7345):1062-5 Hofecker Fallahpour M, Zinkernagel C, Burri B, Stockli G, Wusten R, Stieglitz D, Riecher-Rossler A: Group therapy for mothers with depression. European Psychiatry 2002; 17(0):63.

Hofecker Fallahpour M, Zinkernagel-Burri Ch, Stockli B, Wusten G, Stieglitz RD, Riecher-Rossler A: Group therapy for depression during early motherhood: first results of a pilot study. Nervenarzt 2003; 74(9):767-74.

Klier CM, Muzik M, Rosenblum KL, Lenz G: Interpersonal psychotherapy adapted for the group setting in the treatment of postpartum depression. J Psychother Pract Res 2001; 10(2):124-31.

Klier CM, Schmid-Siegel, Schafer MR, Lenz G, Saria A, Lee A, Zernig G: St. Johnâ&#x20AC;&#x2122;s wort (Hypericum perforatum) and breastfeeding: plasma and breast milk concentrations of hyperforin for 5 mothers and 2 infants. J Clin Psychiatry 2006: 67(2):305-9.

Kripke DF, Tuunainen A, Endo T: Benefits of light treatment for depression. Am J Psychiatry 2006; 163(1): 162-3.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Lee A, Minhas, R, Matsuda N, Lam M, Ito S: The safety of St. Johnâ&#x20AC;&#x2122;s wort (Hypericum perforatum) during breastfeeding. J Clin Psychiatry 2003; 64(8):9668.

Lev-Wiesel R, Daphna-Tekoah S, Hallak M: Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress. Child Abuse Negl 2009; 33(12):877-87.

Lichtenstein AH, Russell RM: Essential nutrients: food or supplements? Where should the emphasis be? JAMA 2005; 294(3):351-8.

Manber R, Schnyer RN, Allen JB, Rush JA, Blasey CM: Acupuncture: a promising treatment for depression during pregnancy. J Affective Disorders 2004; 83:89-95.

Martiny K: Adjunctive bright light in non-seasonal major depression. Acta Psychiatr Scand Suppl 2004; 425:7-28.

Martiny K, Lunde M, Unden M, Dam H, Bech P: The lack of sustained effect of bright light in non-seasonal major depression. Psychol Med 2006; 36(9): 1247-52.

Meager I, Milgrom J: Group treatment for postpartum depression: a pilot study.

Aust N Z J Psychiatry 1996; 30(6):852-60.

Milgrom J, Negri LM, Gemmill AW, McNeil M, Martin PR: A randomised controlled trial of psychological interventions for postnatal depression. Br J Clin Psych 2005; 44: 529-42.

Misri S, Reebye P, Corral M, Milis L: The use of paroxetine and cognitivebehavioral therapy in postpartum depression and anxiety: a randomized controlled trial. J Clin Psychiatry 2004; 65(9):1236-41.

Miyake Y, Sasaki S, Yokoyama T, Tanaka K, Ohya Y, Fukushima W, Saito K, Ohfuji S, Kiyohara C, Hirota Y: Risk of postpartum depression in relation to dietary fish and fat intake in Japan: the Osaka Maternal and Child Health Study. Psychol Med 2006; 36(12):1727-35.

Morgan M, Matthey S, Barnett B, Richardson C: A group programme for postnatally distressed women and their partners. J Advanced Nursing 1997;26:913-20.

Mukaino Y, Park J, White A, Ernst E: The effectiveness of acupuncture for depression: a systematic review of randomized controlled trials. Acupuncture in Medicine 2005; 23(2): 70-6.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Murray L, Cooper PJ, Wilson A, Romaniuk H: Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child relationship and child outcome. Br J of Psychiatry 2003; 182:420-7.

Murray L, Woolgar M, Murray J, Cooper P: Self-exclusion from health care in women at high risk for postpartum depression. J Pub Health Medicine, 2003; 25:2. 131-7.

Narendran S, Nagarathna R, Narendran V, Gunasheela S, Nagendra HRR: Efficacy of yoga on pregnancy outcome. J of Alternative and Complementary Medicine 2005; 11(2):237-44.

O’Hara MW, Stuart S, Gorman LL, Wenzel A: Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry 2000; 57:103945.

O’Higgins M, Glover V, Corral M: Alternative Treatment Strategies for Perinatal Depression and Anxiety. In Riecher-Rössler A, Steiner M (eds): Perinatal Stress, Mood and Anxiety Disorders. From Bench to Bedside. Bibl Psychiatr. Karger.

2005; 173: 182-93.

Onozawa K, Glover V, Adams D, Mobi N, Kumar CR: Infant massage improves mother-infant interaction for mothers with postnatal depression. J Affect Disorders 2001; 63: 201-207 Oren DA, Wisner KL, Spinelli M, Epperson CN, Peindl KS, Terman JS, Terman M: An open trial of morning light therapy for treatment of antepartum depression.

Am J Psychiatry 2002;159(4):666-9.

Parry BL, Currun ML, Stuenkel CA, Yokimozo M, Tam L, Powell KA, Gillin JC: Can critically timed sleep deprivation be useful in pregnancy and postpartum depressions? J Affect Disord 2000; 60(3):201-12.

Partonen T, Magnussen A: Seasonal Affective Disorder: practice and research.

Oxford, Oxford University Press, 2001.

Phillips J, Sharpe L, Matthey S, Charles M: Maternally focused worry. Arch Womens Ment Health 2009; 12(6): 409-18.

Poudevigne MS, O’Connor PJ: Physical Activity and Mood during Pregnancy. J Am Coll Sports Med 2005: 1374-80.

Rees AM, Austin M, Parker: Role of omega-3 fatty acids as a treatment for depression in the perinatal period. Aust NZ J Psychiatry 2005; 39:274-80.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Ross LE & McLean LM: Anxiety disorders during pregnancy and the postpartum period: a systematic review. J Clin Psychiatry 2006; 67(8):1285-98.

Ross LE, Murray BJ, Steiner MD: Sleep and perinatal mood disorders: a critical review. J Psychiatry Neurosci 2005; 30(4): 247-56.

Seng JS, Rauch SA, Resnick H, Reed CD, King A, Low LK, McPherson M, Muzik M, Abelson J, Liberzon I: Exploring posttraumatic stress disorder symptom profile among pregnant women. J Psychosom Obstet Gynaecol 2010; 31(3):176-87.

Sontrop J & Campbell: N-3 polyunsatured fatty acids and depression: A review of the evidence and a methodological critique. Prevent Med 2006; 42:4-13.

Spinelli MG & Endicott J: Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry 2003; 160(3):555-62.

Tornek A, Field T, Hernandez-Reif M, Diego M, Jones N: Music effects on EEG in intrusive and withdrawn mothers with depressive symptoms. Psychiatry 2003; 66(3):234-43.

Ugarriza DN: Group therapy and its barriers for women suffering from postpartum depression. Arch Psychiatr Nurs 2004; 18(2):39-48.

Weier KM, Bier BW: Complementary therapies as adjuncts in the treatment of postpartum depression. J Midwifery Womens Health 2004; 49(2):68-76.

Zinga D, Phillips SD, Born L: Postpartum depression: we know the risks, can it be prevented? Rev Bras Psiquiatr 2005; 27(Supl II):S56-64.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Cunnington M, Ferber S, Quartney G: International lamotrigine pregnancy registry scientific advisory committee. Effect of dose on the frequency of major birth defects following fetal exposure to lamotrigine monotherapy in an international observational study. Epilepsia 2007; 48:1207-10.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 exposure during breast-feeding. J Clin Psychopharmacol 2000; 20(2):285-6.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 McKenna K, Einarson A, Levinson A, Gideon K: Significant changes in antipsychotic drug use during pregnancy. Vet Hum Toxicol 2004; 46(1):44-6.

Meador KJ, Baker GA, Browning N, Clayton-Smith J, Combs-Cantrell DT, Cohen M, Kalayjian LA, Kanner A, Liporace JD, Pennell PB, Privitera M, Loring DW: Cognitive function at 3 years of age after fetal exposure to antileptic drugs.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Ohman I, Vitols S, Tomson T: Lamotrigine in pregnancy: pharmacokinetics during delivery, in the neonate, and during lactation. Epilepsia 2000; 41:709.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Sharma V, Burt VK, Ritchie HL: Assessment and treatment of bipolar II postpartum depression: a review. J Affect Disord 2010;125(1-3):18-26.

Sharma V & Mazmanian D: Sleep loss and postpartum psychosis. Bipolar Disord 2003; 5:98-105.

Sharma V & Penava D: Screening for bipolar disorder during pregnancy and the postpartum period. J Obstet Gynaecol Can 2010; 32:278-81.

Spinelli M: Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill. Washington, DC, Am Psychiatric Publishing, 2003.

Spinelli M: Maternal infanticide associated with mental illness: prevention and the promise of saved lives. Am J Psychiatry 2004; 161:1548-57 Stahl MM, Neiderud J, Vinge E: Thromobocytopenic purpura and anemia in a breastfed infant whose mother was treated with valproic acid. J Pediatr 1997 130:1001.

Stoner SC, Sommi RW, Marken PA Anya I, Vaughn J: Clozapine use in two full term pregnancies. J Clin Psychiatry 1997; 58:364.

Stowe ZN: The use of mood stabilizers during breastfeeding. J Clin Psychiatry 2007; 68(Suppl9): 22-8.

Taylor TM, Oâ&#x20AC;&#x2122;Toole, MS, Ohlsen RI, Walters J, Pilowsky L: Safety of Quetiapine during pregnancy. Am J Psychiatry 2003; 160(3):588-9.

Tomson T, Ohman I, Vitols S: Lamotrigine in pregnancy and lactation: a case report. Epilepsia 1997; 38(9):1039-41.

UNSW Embryology: Beginnings, Growth, and Development. Accessed in December 2010 from http://embryology.med.unsw.edu.au/Medicine/BGDlab11cc.htm U.S. Food and Drug Administration: Risk of oral clefts in infants born to mothers using topimax. U.S Department of Health and Human Services, c2011. Accessed from http://www.fda.gov/Drugs/DrugSafety/ucm245470.htm Viguera AC, Cohen L, Baldessarini RJ, Nonac R: Managing Bipolar Disorder During Pregnancy: Weighing the Risks and Benefits. Can J Psychiatry 2002; 47(5):426-36.

Viguera AC, Nonacs R, Cohen LS, Tondo L, Aoife-Murray AB, Baldessarini RJ: Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psych 2000; 157:179-84.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Viguera AC, Whitfield T, Baldessarini RJ, Newport DJ, Stowe ZS, Reminick A, Zurick A, Cohen LS: Risk of recurrence of bipolar disorder during pregnancy: Prospective study of mood stabilizer discontinuation. Am J Psych 2007; 164:181724.

Walker SP, Permezel M, Berkovic SF: The management of epilepsy in pregnancy. BJOG 2009;116 (6):758-67.

Warner JP: Evidence-based psychopharmacology 3. Assessing evidence of harm: what are the teratogenic effects of lithium carbonate? J Psychopharmacol 2000; 14(1):77-80.

Yatham LN, Kennedy SH, Schaffer A, Parikh SV, Beaulieu S, O'Donovan C, MacQueen G, McIntyre RS, Sharma V, Ravindran A, Young LT, Young AH, Alda M, Milev R, Vieta E, Calabrese JR, Berk M, Ha K, Kapczinski F: Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009. Bipolar Disord 2009; 11:225-55.

Yonkers KA: Management strategies for PMS/PMDD. J Fam Pract 2004; Suppl:S15-20.

Yonkers KA, Little BB, March D: Lithium during pregnancy: drug effects and therapeutic implications. CNS Drugs 1998;4:261â&#x20AC;&#x201C;9.

Yonkers KA, Vigod S, Ross LE: Diagnosis, pathophysiology, and management of mood disorders in pregnant and post partum women. Obstet Gynecol 2011; 117:961-77.

Yonkers KA, Wisner KL, Stowe Z, Leibenluft E, Cohen L, Miller L, Manber R, Viguera A, Suppes T, Altshuler L: Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004; 161:608-20.

Yoshida K, Smith B, Craggs M, Kumar R: Neuroleptic drugs in breast-milk: a study of pharmacokinetics and of possible adverse effects in breast-fed infants.

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Additional References: Abrams R: ECT in Pregnancy. Oxford, Oxford University Press, 1992.

American Academy of Neurology: Practice parameter: management issues for women with epilepsy (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1998; 51, 944Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 8.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association, 2000.

American Psychiatric Association: The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging: A Task Force Report of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 1990.

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Cohen LS, Wang B, Nonacs R, Viguera A, Lemon E, Freeman MP: Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin N Am 2010; 33:273-93.

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Doucet S, Jones I, Letourneau N, Dennis CL, Blackmore ER: Interventions for the prevention and treatment of postpartum psychosis: a systematic review. Arch Womens Ment Health 2011; 14(2):89-98.

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Finnerty M, Levin Z, Miller LJ: Acute manic episodes in pregnancy. Am J Psychiatry 1996; 153(2): 261-63.

Gentile S: Prophylactic treatment of bipolar disorder in pregnancy and breastfeeding: focus on emerging mood stabilizers. Bipolar Disord 2006; 8(3): 207-20.

Holmes LB, Wyszynski DF, Baldwin EJ, Habecker E, Glassman L, Wong SL, Wyszynski DF. Increased risk for non-syndromic cleft palate among infants Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 exposed to lamotrigine during pregnancy. 46th Annual Meeting of the Teratology Society, June 24-29, 2006, Tucson, AZ. Liebenluft E: Women with bipolar illness: clinical and research issues. Am J Psychiatry 1996; 153:163-73.

Leibenluft E: Issues in the treatment of women with bipolar illness. J Clin Psychiatry 1997; 58(15):5-11.

Matevosyan NR: Pregnancy and postpartum specifics in women with schizophrenia: a meta-study. Arch Gynecol Obstet 2011; 283(2):141-7.

Merck & Co: Valproic acid and derivatives drug information provided by LexiComp. Accessed in December 2009 from http://www.merck.com/mmpe/lexicomp/valproic%20acid%20and%20derivatives.h tml.

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Oates M: Suicide: the leading cause of maternal death. Br J Psychiatry 2003; 183:279-81.

Ohman I, Vitols S, Luef G, Soderfeldt B, Tomson T: Topiramate kinetics during delivery, lactation, and in the neonate: preliminary observations. Epilepsia 2002; 43(10):1157-60.

Pedersen LH, Henriksen TB, Vestergaard M, Olsen J, Hammer Bech B: Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: population based cohort study. BMJ 2009; 339:b3569.

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Sacker A, Done DJ, Crow TJ: Obstetric complications in children born to parents with schizophrenia: a meta-analysis of case control studies. Psychol Med 1996; 26:279-87.

Viguera AC, Baldessarini RJ, Tondo L: Response to lithium maintenance treatment in bipolar disorders: comparison of women and men. Bipolar Disord 2001; 3(5): 245-52.

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165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012 Viguera AC, Newport J, Ritchie J, Stowe ZN, Whitfield T, Mogielnicki J, Ross J, Baldessarini, Zurick A, Petrillo LF, Cohen LS: Lithium in breast milk and nursing infants: Clinical Implications. Am J Psychiatry 2007; 164(2):342-5.

Viguera AC, Newport J, Ritchie J, Stowe ZN, Whitfield T, Mogielnicki J, Ross J, Baldessarini, Zurick A, Petrillo LF, Cohen LS: Lithium and Lactation. APA Poster 2005.

Yamasmit W, Chaithongwongwatthana S, Tolosa JE: Prenatal vitamin K1 administration in epileptic women to prevent neonatal hemorrhage: is it effective? J Reprod Med 2006; 51(6):463-6.

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Self-Assessment The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s).

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Self Assessment Questions: One Best Response 1. For a woman with a prior history of depression, the most effective method of treatment during pregnancy would likely be: a. monitor her mood closely b. treat her prophylactically with SSRIâ&#x20AC;&#x2122;s c. seek support for her from her family and friends d. see her frequently in the postpartum period e. all of the above 2. Biological risk factors for post-partum depression (PPD) include: a. previous history of PPD b. family history of schizophrenia c. fall in levels of progesterone and estrogen d. history of abuse 3. If a woman conceives accidentally while using an antidepressant, the best course of action is to: a. stop all medications b. evaluate her individual risk factors for relapse c. switch to St. Johnâ&#x20AC;&#x2122;s Wort d. immediately reduce dose 4. Neonatal withdrawal syndrome: a. is transient in nature b. Occurs in perinatal SSRI/SNRI exposure c. is found in severely mentally ill women d. all of the above 5. Perinatal Panic disorder is best treated with: a. Anti-anxiety medication b. Cognitive Behavioral Therapy (CBT) c. Antipsychotics d. CBT & Antidepressants e. All of the above

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

6. Obsessive Compulsive Disorder in pregnancy presents with: a. Obsessional thoughts of harming the infant b. Intrusive thoughts of inappropriate sexual touching c. Compulsive checking and rechecking d. Repeated hand washing e. All of the above

7. Prenatal anxiety has consequences for: a. the fetus b. the neonate c. preschool/adolescent children d. all of the above 8. Ebsteinâ&#x20AC;&#x2122;s anomaly is primarily associated with the administration of one of the following medications during pregnancy: a. lithium b. benzodiazepines c. haloperidol d. tricyclic antidepressants e. carbamazepine 9. Psychosis during pregnancy: a. occurs in women who have marital problems b. is common among single mothers c. occurs only in the first trimester d. occurs in women with prior histories of psychiatric illnesses

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada

165th APA Annual Meeting, Philadelphia, Pennsylvania, 2012

Self Assessment Answers 1. e 2. a 3. b 4. d 5. e 6. e 7. d 8. a 9. d

Management of Psychiatric Disorders in Pregnant & Postpartum Mothers Reproductive Mental Health Program, Vancouver, BC, Canada