Education on Postpartum Mood and Anxiety Disorders and available treatment.

1. Perinatal Mood
and Anxiety
Disorders
St. Mark’s Behavioral Health
Intensive Outpatient Program
Melissa Timpson, CSW

2. “What is wrong with me?”
Maternal Mental Health Complications

3. National Coalition for Maternal
Mental Health
– https://youtu.be/U8ZSUzJ0KqU
According to the NCMMH, 1 in 7 women experience Maternal Mental
Health Complications. Each year more than 600,000 women, children, and
families are impacted by a maternal mental health complication,
including; postpartum depression, pregnancy depression, postpartum
and pregnancy anxiety, panic, OCD, and anger. However, it is one of the
most under treated and overlooked complication of childbirth.
Published on Feb 3, 2016

4. “Is this normal?”
Screening & The Therapeutic Alliance

5. Screening Tools & Needs Assessment
– Edinburgh Postnatal Depression Screening Tool
– 10 question screening assessment, free and easy to access.
– Providers (OBGYN/Midwife/Doula/Primary Care Physician)
– Community Resources
– Support System
– Stressors (i.e. occupational, primary support, financial)
– Child Care needs

6. The Therapeutic Relationship is developed by:
– Validation
– Empathy
– Encouragement
– Framing, holding, contextualizing
– Engaging support and follow through
– Creating new interpretation of baby’s responses
– Creating a safe place for parents to process and question

7. “I thought it was just
the Baby Blues.”
Perinatal Mood and Anxiety Disorder
Diagnostic Criteria

8. Depression Symptoms
– Sadness, Excessive Crying
– Unexplained Physical Complaints
– Suicidal Thoughts; Different from Intrusive Thoughts
– Appetite Changes, Sleep Disturbances
– Poor Concentration/Focus
– Irritability and Anger
– Hopeless and Helpless
– Guilt and Shame
– Apathy towards self and/or others, Isolation
– Lack of self care
– Anhedonia, Worthlessness

9. Anxiety Symptoms
– Agitated, irritable
– Inability to sit still
– Excessive concern about Baby’s or her own health
– High Alert
– Appetite changes-often rapid weight loss
– Sleep disturbances (difficult falling/staying asleep)
– Constant worry
– Racing thoughts
– Shortness of breath
– Heart Palpitations

10. Panic Symptoms
– Episodes of extreme anxiety
– Shortness of breath, chest pain, sensations of choking or smothering, dizziness
– Hot or cold flashes, trembling, rapid heart rate, numbness or tingling sensations
– Restlessness, agitation, or irritability
– Excessive worry or fear
– Panic may wake her up or keep here from sleeping
– Fear of Dying, Fear of Going Crazy, and/or Fear of Losing Control

11. Obsessive-Compulsive Disorder
– Checking on baby’s breathing excessively
– Obsession with cleaning/Fearful of germs
– Counting Diaper Changes/Milk Intake
– Tremendous Guilt and Shame
– Hypervigilance
– Engagement in behaviors to avoid harm or minimize triggers.
– Horrified by Intrusive, repetitive thoughts-usually of harm coming to baby (Abramowitz J. et al. Arch
Women’s Mental Health 2010; 13(6): 523-530)
– History of OCD (often unrecognized)
– 65% have co-morbid depression

12. Post-Traumatic Stress Disorder
– Re-experiencing traumatic events (flashbacks and flooding)
– Distressing memories, thoughts, feelings or external reminders of the event
– Spontaneous memories of the traumatic event
– Recurrent dreams/nightmares
– Avoidance of triggers
– Isolation from family/friends/providers
– Persistent and distorted sense of blame of self or others
– Numbing, hyper-arousal/hypervigilance, Disassociation
– Markedly diminished interest in activities, to an inability to remember key aspects of
the event.
– **Birth Trauma verses After Childbirth Trauma

13. Trauma Themes
– Perception of lack of caring:
– Felt abandoned
– Stripped of dignity/autonomy
– Lack of support and reassurance
– Poor communication:
– Feeling invisible or unheard
– Feeling of powerlessness:
– Betrayal of trust, didn’t feel protected by staff
(Beck, CT, Virth Trauma; in the Eye of the Beholder, Nursing Research (2004) 53, 28-35)

14. Perinatal Bipolar Disorders
– Hypomania verse Mania Episodes
– Elevated Mood Symptoms:
– Euphoria or Agitation
– Decreased need for sleep
– Racing thoughts
– Increased productivity
– Noticed by others
– Pressured speech
– Increased energy
– 22.6% of women who screened positive for postpartum depression had a bipolar disorder
(Wisner K. et al. JAMA Psychiatry. 2013;70(5):490-498).

15. Psychosis
– Delusions (e.g. baby is possess by a demon)
– Hallucinations (e.g. seeing someone else’s face on baby, or hearing voices)
– Insomnia
– Confusion/Disorientation
– Rapid Mood Swings
– Waxing and Waning (moments of normal functioning between psychotic episodes).
– 50% of 1st time moms with psychosis had no previous psychiatric Hospitalization
(Caldimarsdottir U. et al. 2009. PLoS Med 6(2)
– Onset usually within first 2 weeks after delivery (Monzon C. et al. Psychiatric Times January 15, 2014)
– 1-2 in 1,000 Postpartum Women will develop Psychosis, of those women: 5% suicide
and 4.5% infanticide will occur. (Brockington, I. Arch Women’s Mental Health. 2017;201(1):63-69)

16. “I have thoughts about
hurting my baby and it
scares me”
Intrusive Thoughts, Anxiety, Fear & Shame

17. Intrusive Thoughts
– VERY COMMON experience
– Educate that thoughts does not equal action
– Cognitive Behavioral Techniques
– Typically mother doesn’t want to harm baby and will go out of their way to
ensure baby’s safety
– The thoughts is obsessive in nature and odd/frightening to mother
– Mother has no delusions or hallucinations related to harming baby
– Should be treated in an individual session, avoid sharing other examples and/or
group discussion of detailed thoughts.

18. “How do I help my
spouse/partner?”
Perinatal Mood & Anxiety Disorders

19. Effects on Spouse/Partners
– 1 out of 10 partners experience moderate to severe depression symptoms.
– He/She may feel:
– Helpless
– Worthless
– Underappreciated
– Angry
– Avoidant
– Fearful
– Frustrated
– PMAD in the first two months postpartum vary from 4 to 25%, with the highest peak
when baby is 3-6 month period. (Paulson, JF & SD Bazemore, JAMA, 2010; 303(19): 1961-1969)

20. “Why is this happening to
me, what did I do wrong?”
Risk Factors and Exacerbating Factors

21. Risk Factors
– Risk Factors are Universal and can be identified through screening process
– Previous Postpartum Experience (personal and family)
– History of Mood/Anxiety Disorder (personal and family)
– Significant mood reactions to hormonal changes (Puberty, PMS, Birth Control)
– Socioeconomic Factors
– High Stress/Environmental Factors
– Endocrine Dysfunction
– Type I or Type II Diabetes (not increased with gestational diabetes)

22. Exacerbating Factors
– Physical Pain, Lack of sleep
– Abrupt discontinuation of breastfeeding, Dysphoric Milk Ejection Reflex (D-MER
Disorder)
– Childcare stress/Relationship Stress
– Loss: miscarriage, neonatal death, stillborn, selective termination, elective abortion
– History of Childhood Sexual Abuse (ACES Study)
– Health complications of baby and/or parents
– Temperament of Baby
– Social Media/Cultural Pressures
– Complications in pregnancy, birth, or breastfeeding (“breast is best” verses “fed is
best”)

23. “When will I be myself
again?”
Available Treatment Options
Multidisciplinary Team

24. Evidence Based Treatment
Modalities:
– Cognitive Behavioral Therapy
– Interpersonal Psychotherapy
– Peer Support
– Psycho-Educational Group Therapy
– Mother-Infant Therapy and Education
Length:
– Treatment varies due to client needs, therapeutic rapport and severity of symptoms
– “Conventional wisdom is that psychotherapeutic treatments for mild to moderate
depression should be provided for 10-12 weeks.” (Stuart. O’Hara, & Gorman (2003) Archives of Women’s Mental
Health, 6(2), 57-69)

25. Therapeutic & Medical Interventions
– Psychotropic Medications
– Trans Magnetic Stimulation
– Hospitalization
– Intensive Outpatient Treatment
– Community Support Groups
– Individual Counseling
– Couples Counseling
– Family Education/Counseling
– Group Therapy
– Mom/Baby Dyad

26. Support & Treatment Team Members
– Healthcare Providers
– Psychiatric Providers
– Pharmacists
– Psychological Services
– Social Support Network
– Doulas
– Parent/Childbirth Educators
– Lactation Consultants
– Spiritual Support

27. “Do I have to take
Medications?”
Traditional, Holistic and
Complimentary Approaches

28. Common Psychotropic Medications:
– Treatment with SSRIs during pregnancy was related to a lower risk of preterm birth
and cesarean section compared to untreated women with mental health disorders
(Malm H. Et al. Am J Psychiatry 2015;172:1224-1232)
– SSRIs have been the most studied medication in pregnancy and there have been NO
consistent fetal malformations or abnormalities documented with any SSRIs (Weisskopf E.
et al. Expert Opin. Drug Saf. (2014) 14(2))
– Celexa 10mg-20/40mg
– Lexapro 5mg-10/20mg
– Prozac 10mg-20/40mg
– Paxil 10mg-20/40mg
– Zoloft 25mg-75/200mg
– American Journal of Obstetrics and Gynecology 2012:
“When a psychiatric condition necessitates pharmacotherapy, the benefit of such therapy far
outweigh the potential minimal risks”. (Koren, G., Nordeng H., AJOG (2012)).

29. Alternative Treatment Modalities
– Bright Light Therapy
– Aromatherapy
– Bio-feedback
– Mindfulness Based Stress Reduction (MBSR)
– Prenatal Massage, Massage and Yoga
– Acupuncture, Herbal Remedies
– Dietary Supplements, Nutritional Changes
– Exercise, Sleep Hygiene

30. “Will this happen again if I
have other children?”
Elements of Prevention

31. Primary Prevention Model
– “…Prevention is the great
challenge of postnatal illness
because this is the one of the few
areas of psychiatry in which
primary prevention is feasible…”
(Hamilton & Harberger. In Postpartum Psychiatric Illness:
a Picture Puzzle (1992))
– Population is already in contact
with healthcare providers
– Clear markers and defined period
of risk (pregnancy and postnatal)
– Common peak of risk: most
prevalent 3 months after birth
– These risk factors can be impacted
by primary prevention efforts

32. Alternative Prevention Models
– Secondary Prevention:
– Reduce severity and duration of
symptoms when PMAD occurs
– Tertiary Prevention:
– Improve functioning, relationships,
and prognosis for women and
their offspring.
– Additional Elements of Prevention:
– Education
– Mobilize support network
– Access resources
– Crisis prevention planning
– Adequate sleep, rest, nutrition, exercise,
medication (if needed).

33. Additional
Resources &
Support Available
Upon Request
Thank you!