Taking Care of the Tree
Chris Raines MSN APRN-BC
Associate Director, Obstetrical Liaison and Community
Outreach
UNC Perinatal Psychiatry Program
Take Care of the Tree
Trunk and the
Branches will survive
Care of the Tree
How do you take care of a Tree
Water
Nutrients
Fertilizer
Protect the Roots
Sunlight
Care of the Tree
How do we take care of Ourselves
Mood Disorders in Women in the
General Population
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Depressive disorders are very common
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Lifetime prevalence rates range from 4.9-17.1 percent
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Women report a history of major depression at nearly
twice the rate of men
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Depression is now considered the leading cause of
disease-related disability among women in the world.
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Women of childbearing age are at high risk for major
depression
Perinatal Mood Disorder
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COMMON
1 in 7 women…15% prevalence rate
 4 million women give birth annually in U.S.; ½ million with
PPD
 Most common, complication of perinatal and postpartum
period
 Compare to prevalence rate of gestational diabetes at 2-5%
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MORBID
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Devastating consequences for patient and family
 low maternal weight gain, preterm birth
 Impaired bonding between mother and infant
 Increased risk of suicide and infanticide
Risk of Relapse of Major
Depression in Pregnancy

High risk of depressive relapse following antidepressant
discontinuation during pregnancy ( Cohen et al, JAMA,
2006).
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Of 201 women in the sample, 86 (43%) experienced a relapse
of major depression during pregnancy.
Women who discontinued medication relapsed more
frequently (68% vs 26%) compared to women who
maintained medication (hazard ratio, 5.0; 95% confidence
interval, 2.8-9.1; P<.001).
 Pregnancy is not "protective" with respect to risk of
relapse of major depression
Care of the Tree
Why do women stop their medications
FEAR of harm to the unborn child
Pressure from Family
Medical Provider tells them to stop
I can handle my depression for 9 months
GUILT
STIGMA
Risks of Untreated Antenatal
Depression
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Associated with low maternal weight gain, increased rates of
preterm birth, low birth wt, increased smoking, ETOH and
other substances
Increased ambivalence about the pregnancy and overall worse
health status.
Prenatal exposure to maternal stress has consequences for the
development of infant temperament.
Children exposed to perinatal maternal depression have higher
cortisol levels than infants of mothers who were not depressed,
and this continues through adolescence.
Maternal treatment of depression during pregnancy appears to
help normalize infant cortisol levels.
Care of the Tree
How do we take care of Ourselves
Guilt
“Guilt is a cognitive or an emotional experience that occurs
when a person realizes or believes-accurately or not- that he or
she has compromised his or her own standards of conduct or
has violated a moral standard”
Wikipedia
Care of the Tree
How do we take care of Ourselves
Stigma
“ a set of negative and often unfair beliefs
that a society or group of people have about
something”
Merriam-Webster
Documentary
Dark Side of the Full Moon
Jennifer Silliman
Maureen Fura
http://www.youtube.com/watch?v=DyYXhgEhcXg
Treatment
Perinatal Mood Disorders
Treatment
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One size does not fit all!!
Critical for the well being of the woman ,baby and
family
Effective treatments are readily available
Psychotherapy
 Medication Management
 Other, alternative
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Skilled assessment and treatment by mental health
professionals in perinatal psychiatry makes a difference
in outcomes
Screening Instruments
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Edinburgh Postnatal Depression Scale (EPDS)
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Most commonly employed screening tool
Beck Depression Inventory (BDI)
Montgomery-Asberg Depression Rating Scale
(MADRS)
Hamilton rating Scale for Depression (HRSD)
Nine Symptom Depression Checklist of the
Patient Health Questionnaire (PHQ)
Edinburgh Postnatal Depression Scale (EPDS)1,2
Ask patient how they have been feeling OVER THE LAST 7 DAYS, not just today
To use calculator, click on appropriate answer and score appears in box when all
questions completed
1. I have been able to laugh and see the funny side of things *
2. I have looked forward with enjoyment to things *
3. I have blamed myself unnecessarily when things went wrong
3 points - Yes, quite often
2 point - Sometimes
1 point - Hardly ever
4. I have been anxious or worried for no good reason *
Edinburgh Postnatal Depression Score = /30
5. I have felt scared or panicky for no very good reason
6. Things have been getting on top of me
7. I have been so unhappy, I have had difficulty sleeping
8. I have felt sad and miserable
9. I have been so unhappy that I have been crying
10. The thought of harming myself has occurred to me
* Questions 1, 2, and 4 are scored in reverse order (0-3)
UNC Center for Women’s Mood
Disorders:
Perinatal Psychiatry Program
Clinical and Research Program
that provides assessment, treatment and
support for women in the
perinatal period
Collaboration of doctors, nurses,
midwives,
therapists, & social workers
www.womensmooddisorders.org
UNC Center for Women’s Mood Disorders:
Perinatal Psychiatry Inpatient Unit
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1st free-standing Perinatal Inpatient Unit in the US—
renovated summer 2011
Provides specialized comprehensive assessment and
treatment
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Medication stabilization
Individual and group counseling and behavioral therapy
Partner assisted therapy , maternal-infant interaction,
spirituality, biofeedback, yoga, psycho-education for both
patients and spouses
Family therapy
UNC Center for Women’s Mood Disorders:
Perinatal Psychiatry Inpatient Unit
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Protected sleep times
Gliders and hospital grade pumps, supplies, and
refrigerator for milk storage
Specialty perinatal nursing staff
State-of-the art treatment
Extended visiting hours to maximize
positive mother-baby interaction
UNC Center for Women’s Mood
Disorders:
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Outpatient Services: Evaluation, Medication
Management, and Therapy
NP embedded in OB High Risk
 NP embedded in Peds Clinic
 Satellite Clinic at Rex Hospital
 Tele med Psychiatry for outlying rural Clinics
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Support group
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2nd and 4th Tuesday of each month 6:30-8p-free
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References
Andrade SE, McPhillips H, Loren D, Raebel MA, et al. Antidepressant medication
use and risk of persistent pulmonary hypertension of the newborn.
Pharmacoepidemiol Drug Saf. 2009 Mar;18(3):246-52
Gavin N, Gaynes B, Lohr K, Meltzer-Brody S. et al. 2005 Perinatal depression: a
systematic review of prevalence and incidence.
Obstet Gynecol. 106:1071-83
Cohen L, Altshuler L, Harlow B, Nonacs R. 2006. Relapse of major depression
during pregnancy in women who maintain or discontinue antidepressant
treatment. JAMA. 295(5):499-507
Chambers C, Hernandez-Diaz S, VanMarter L, Werler M. 2006. Selective
serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of
the newborn. N Engl J Med. 354(6):579-87.
Delatte R, Meltzer-Brody S, Cao H, Menard K. 2009 “Universal Screening for
Postpartum Depression: An Inquiry into Provider Attitudes and Practice
American Journal of Obstetrics and Gynecology, 200(5):e63-4.
Einarson A, Choi J, Koren G 2009 Incidence of major malformations in infants
following antidepressant exposure in pregnancy: results of a large prospective
cohort study. Canadian Journal of Psych, 54(4):242-6.
McKenna K, Koren G, Tetelbaum M, Wilton L et al. 2005 Pregnancy outcome of
women using atypical antipsychotic drugs: A prospective comparative study. J Clin
Psychiatry: 66:444-449.
References
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Meltzer-Brody S, Payne J, Rubinow D. 2008 Postpartum Depression: Evolving
Etiology & Treatment Considerations, Current Psych, 7(5):87-95.
Meltzer-Brody S, Hartmann K, Miller W, Scott J. 2004 A brief screening
instrument to detect posttraumatic stress disorder in outpatient gynecology.
Obstet Gynecol.104(4):770-776.
Oberlander TF, Warburton W, Misri S et al. 2006 Neonatal Outcomes After
Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants
and Maternal Depression Using Population-Based Linked Health Data. Arch
General Psychiatry :63:898-906.
Sit D, Rothschild A, Wisner K. 2006 A Review of Postpartum Psychosis, Journal
of Women’s Health: 15(4):352-368.
Viguera A & Cohen L. 1998. The course and management of bipolar disorder
during pregnancy. Psychopharmacology Bulletin 34:339-353.
Viguera A, Cohen L et al. 2002 Managing bipolar disorder during pregnancy:
weighing the risks and benefits. Can J Psychiatry. 2002 Jun;47(5):426-436.
Webb R, Abel K, et al. 2005 Mortality in Offspring of Parents with Psychotic
Disorders: A Critical Review and Meta-Analysis, Am J Psych:162:1045-1056
Yonkers K, Wisner K, Stowe Z, et al. 2004. Management of Bipolar Disorder
during pregnancy and the postpartum period. Am J Psychiatry:161:608-620