Sponsored by the
POSTPARTUM DEPRESSION PROJECT
MAINE ASSOCIATION OF PSYCHIATRIC PHYSICIANS
(MAPP)
CRISIS EVALUATION OF THE
PREGNANT AND POSTPARTUM
WOMAN:
What to know on the frontlines
Goals of this presentation:
1. Understand the importance of recognition of
depression in pregnant and postpartum women
2. Know the spectrum of perinatal mood disorders
3. Know what represents a true psychiatric
emergency
4. Know what circumstances raise the risk of harm to
the baby
5. Recognize postpartum psychosis
6. Understand the consequences of untreated
perinatal depression
7. Know how to assess the level of care needed
8. Discuss some typical case presentations
Important Points:
• Depression and other mental illness during
pregnancy and postpartum most often is
undiagnosed and untreated.
• There is tremendous societal pressure to
present as happy and well functioning during
these times.
• Women fear stigma, being judged as bad
mothers, having their children taken away
and that treatment with medication will
harm their babies
Important Points:
• Women seeking out care are most often
feeling frightened, ashamed and extremely
vulnerable
• There are 2 “clients” to consider: mother and
baby
• NONJUDGMENTAL AND INFORMED
ASSESSMENT IS KEY
DEPRESSION DURING PREGNANCY
• Between 10-20% of women will experience
significant depression during pregnancy
• This will be a first episode for one third
• Routine screening for depression during pregnancy
is uncommon
• Typically depression during pregnancy is untreated
or incompletely treated
• Women who have discontinued their psychotropic
medication in order to get pregnant are at high risk
for relapse
SIGNIFICANCE
Untreated depression during
pregnancy is associated with
serious short term risks and long
term mental health and health
consequences for mother and
her baby.
THE MOST COMMON
COMPLICATION OF
CHILDBIRTH IS
DEPRESSION
Epidemiology of Postpartum Episodes
70
Admissions/Month
60
50
40
30
20
Pregnancy
10
0
–2 Years
– 1 Year
Childbirth
+1 Year
+2 Years
Kendell RE et al. Br J Psychiatry. 1987;150:662-673.
Spectrum of Postpartum Mood Disorders
Postpartum Psychosis
Postpartum
Symptom
Severity
Postpartum Depression
(10-15%)
Postpartum Blues
(50-85%)
None
BABY BLUES
• Baby Blues usually develop 3-5 days after
delivery
• Hallmark is emotional reactivity
• Occur in 70-80 % of all new mothers
• Normal reactions to the hormonal changes
and stress of having a baby
• “Baby blues” persisting beyond 2 weeks or
showing signs of worsening raise questions
about PPD
PPD: EARLY RECOGNITION
• PPD is most often missed despite multiple contacts
with health care providers
• The most significant factor in the duration of PPD is
delay in receiving treatment
• Depression often persists for months to years after
childbirth, with lingering effects on physical and
psychological functioning following recovery from
depressive episodes
12
RISK FACTORS
• Depression during pregnancy is the best predictor of post partum
depression
• Prenatal anxiety
• History of mood disorder, especially PPD and bipolar disorder
• Recently having stopped antidepressants or other psychotropics prior to
pregnancy
• Past history of trauma
• Pregnancy or neonatal loss or complications
• Difficult infant temperament
• Lack of social support or marital conflict
• Recent loss or stressful life events
• History of sexual abuse
• Low self esteem
• Breastfeeding difficulties
PRESENTATION OF PPD
• Usually develops slowly over the first three
months, often beginning within the first 4
weeks, though some women have a more
acute onset
• May affect ability to care for the baby
• Signs and symptoms are those of Major
Depression---depressed mood, irritability,
loss of interest and appetite, fatigue
insomnia.
• Often complain of being physically and
emotionally exhausted
PRESENTATION OF PPD
Some common features:
• Often express concerns about her ability to
care for her baby or anxiety about the baby’s
well being
• Anxiety symptoms are common including
frank panic disorder, hypochondriasis, and
most common, generalized anxiety disorder
• Women are often unable to sleep even when
given the opportunity
PRESENTATION OF PPD
• Frequently have intrusive, obsessional
ruminations
• Usually focused on the baby, often violent in
nature
• Egodystonic , VERY troubling to mothers
• NO problem with reality testing i.e. nonpsychotic.
• One study showed 50% of women with PPD
had these obsessional thoughts
VERY IMPORTANT TO DISTINGUISH
OBSESSIONAL THOUGHTS FROM PSYCHOSIS!
• NOT associated with psychotic symptoms
• Experienced as inside the head
• May be experienced dramatically as images in
the mind, e.g. as knives or bloody babies, etc
• Are often accompanied by protective or
avoidant behaviors, e.g. hiding all the knives,
refusing to bathe the baby, similar to the hand
washing used to neutralize the anxiety of fears
that accompany OCD
• DO NOT increase the risk of harm to the baby
• DO NOT necessitate separating mother and baby
Questions to Ask:
“Woman who have just had babies commonly
report having a lot of anxiety including
repetitive scary thoughts …..”
– Have you been having any scary thoughts?
– Have you been experiencing any
frightening thoughts or images that you
just can’t get out of your head?
POST PARTUM PSYCHOSIS
• A PSYCHIATRIC EMERGENCY WHICH
REQUIRES IMMEDIATE INTERVENTION
• Typical onset is within 2 weeks after delivery,
first symptoms often within 48-72 hours
• Earliest signs are restlessness, irritability and
insomnia
• Often very labile in presentation
• Often looks “organic” with a lot of confusion
and disorientation
• Most often consistent with mania or a mixed
state
POST PARTUM PSYCHOSIS
• Includes agitation, paranoia, delusions,
disorganized thinking and impulsivity
• Thoughts of harming the baby are frequently
driven by delusions—Child must be saved from
harm, child is malevolent, dangerous, has special
powers, is Satan or God
• Auditory hallucinations instructing the mother to
harm herself or the child are common
• Rates of infanticide associated with untreated
postpartum psychosis have been estimated to be
as high as 4%.
Other Considerations
• The onset or worsening of OCD, PTSD and
panic disorder can also occur postpartum.
There can be considerable overlap with PPD.
• PTSD can develop in response to a traumatic
birth experience or pregnancy loss
• PTSD can emerge in pregnancy when past
physical or sexual trauma is reexpereinced
• Often are intermingled with symptoms of
PPD
Postpartum Psychiatric Illness
Associated with Significant Mortality
• Suicide rate is increased 70 fold in
the postpartum year
• Women with severe postpartum
psychiatric illness also have a higher
risk of death from other causes
Decision Making about Level of Care
• Safety –of mother and baby; i.e. risk of
suicide, harm to baby, capacity to care for
herself and the baby
• Presence of psychosis
• Availability of care– medical and mental
health care providers familiar with perinatal
illness
• Access to care – both availability and
mother’s capacity and willingness to access
INVOLVING THE FAMILY and OTHERS
• Isolation and feeling overwhelmed are often
huge problems
• Need to also assess the level of psycho social
support
• Need to assess the woman’s willingness and
capacity to accept it– may need to encourage
her acceptance
• Whether or not a woman can manage at
home is hugely influenced by these factors
Treatment intervention
SELECTION OF TREATMENT:
Hospitalization:
Necessary for postpartum psychosis, acute
suicidality, severe depression without adequate
support in the community
Disadvantage:
• This involves separating the mother and baby
which may or may not always be ideal
• We do not have specialized inpatient facilities for
treating postpartum illness
Treatment intervention
Outpatient treatment:
Appropriate if supports are available, resources are
good, and no imminent risk
Advantages:
• Does not separate mother and baby
• Supports often rally in a crisis
Disadvantages:
• Sometimes women benefit from a relief of responsibility
from child care
• Not all provider are adequately trained in providing care to
women with perinatal mental illness
• PCP’s, OB’s, are not always easily reached at the time that
women present to crisis services
Treatment Intervention
These women need follow-up calls
Postpartum Support International (PSI
www.postpartum.net is an
extremely important resource and
has a Maine contact
Treatment of PPD
Selection of treatment:
• **First requires good evaluation, review of
prior history and assessment
forsuicidality/dangerousness
• Individual psychotherapy--CBT /IPT
• Medication can be used with relative safety
in nursing mothers
• Support groups
• Community support programs
• Hospitalization
Treatment of Postpartum Psychosis
• Requires inpatient hospitalization
• Get treated as affective psychosis—i.e. as
Bipolar disorder
• Medication treatment is necessary beginning
with an antipsychotic/mood stabilizer such as
Zyprexa/Lamictal
• ECT is rapid and effective
Role of the Crisis Worker
Evaluation and Triage
You also provide a very important FIRSTLINE
INTERVENTION:
Be sensitive– “those thoughts are very scary
but they are not uncommon”
Be reassuring— “this will get better, it’s not
your fault”
Be knowledgeable, provide education– “PPD is
common and affects many mothers”
REMEMBER:
• Perinatal mood disorders have a significant
impact on the current and future health of
mother and child and stresses the
functioning of the family.
TREATMENT FOR THE MOTHER IS AN
EARLY INTERVENTION OR
PREVENTION FOR THE CHILD
CASE PRESENTATIONS,
QUESTIONS, AND
DISCUSSIONS
CASE # 1
A 30 y/o married mother of 4 year old and 7 month
old sons revealed that she was having intrusive violent
images of harming her infant son. The patient
reported that she had similar violent images after the
birth of her first son and that she was generally more
stressed and anxious then because her first baby
“never slept.” They also had just moved to the area
and she was isolated and without support. She had
intrusive images in which she would see herself
putting the baby in a pot of boiling water. She was
horrified by the images and could not imagine ever
harming her baby. She managed these thoughts and
images which were the most intense when she was
in the kitchen by either moving the baby out of the
kitchen or keeping him on the periphery while she
worked in the kitchen. Gradually over months, as the
baby slept better and she became more involved with
activities and established new relationships her
anxiety and the depression that accompanied it
subsided. She was so horrified that she never
disclosed these experiences to anyone. She did well
for the subsequent 3 years and through her next
pregnancy though was fearful that this experience
would recur following the birth of her second son. She
began to have the same intrusive thoughts and
images soon after he was born. Despite this baby
being a good sleeper and not having the same
level of exhaustion, the images and thoughts persisted
and had been so horrifying that her anxiety escalated
to the point of panic attacks on a couple of occasions.
She was by horrified images of putting this baby in a
pot of boiling water as she would never want to harm
her baby. She had begun to have disturbed sleep and
to experience some depressive symptoms as well. She
had no history of prior psychiatric treatment. She
sought help from her PCP because of her increasing
anxiety and the distress caused by the frequency of
the disturbing thoughts and images of hurting her
baby. Her PCP evaluated her and gave her a
prescription for Zoloft, but sent her to the ED to be
evaluated by the crisis team.
CASE # 2
This is a 32 year old woman whose husband called
with concern about her. She is 10 days postpartum
with their second child. She is usually very upbeat,
busy, talkative, and he was concerned that she is just
“not herself”. She has a prior history of PPD with their
first child. He was advised to bring her into the ED.
She reported that she was “okay, but just unable to get
much sleep”. She was noticed to be easily distractible,
unfocused and to be unable maintain eye contact, but
there was nothing else remarkable on her mental
status exam. She was advised to follow-up with
outpatient care including her OBGYN and told to call
the crisis line if things worsen. He called back urgently
the following day saying that she was much worse and
brought her to the ED. She walked stiffly and
robotically with a blank stare. When asked if she was
okay, she answered abruptly “No!” but didn’t
elaborate. Her husband disclosed that she told him
that she heard people talking in her head. He found her
sitting in front of the window for an extended period of
time seemingly unaware that the baby was crying.
When he asked her what she was doing, she abruptly
came to and said “nothing.” Later she told him God
would surely punish her for being a bad mother.
CASE # 3
This a 28 year old married white female who presents
in her 6th month of pregnancy. This is her 2nd
pregnancy, but her first baby died having been born
prematurely at 27 weeks with an infection. She
suffered from depression following the loss of that
baby but did not receive any treatment. She reports
that this pregnancy has been going well and that all of
the ultrasounds and tests indicate that the baby is
healthy. She has been anxious from the start of the
pregnancy however as she feared that would
experience another loss. She has had increased
anxiety symptoms over the past week, has had
difficulty sleeping and has lost her appetite. For the
past three nights she has woken up with anxiety
attacks and has been unable to get back to sleep. She
finds herself focused on the experience of previous
pregnancy loss. She is scheduled for an ultrasound at
the end of the week, but instead of looking to that for
reassurance she is terrified of going to the test and
uncertain if she can “even get there”. She has been
crying and sad, no longer feeling any joy in having a
baby; instead she only has fear of the potential loss of
one.
CASE # 4
This is a 29 year old married woman who is 3 months
postpartum with her 3rd child. Her first two
pregnancies and postpartum periods were uneventful.
This pregnancy was complicated by premature labor
and the need to be on bed rest for several weeks. This
was very stressful since her first 2 children are ages 5
and 7 and she felt that she was not able to be a good
mother to them while she was on bed rest. Her
delivery was uncomplicated and her baby was born
healthy but early at 35 weeks. The initial postpartum
period was stressful because the baby had
difficulty latching on when nursing. This had gone
very easily with her first 2 babies and she hadn’t
expected this. She had hoped to be able to give
more attention to her older children now that she
was off bed rest but the new baby was so hard to
nurse and it took so much time. She also worried
that he wasn’t getting enough to eat because he
wanted to eat so frequently. In fact, even when he
was sleeping she was worrying about the next
feeding. She worried about his gaining enough
weight and whether or not he was okay. She
checked on him 4 or 5 times every time he was
sleeping to make sure he was breathing okay.
At the same time, she was not sleeping and was only
eating to keep up her milk supply since she had no
appetite. She told her doctor that she couldn’t sleep
and her doctor prescribed some sleep medication but
she was so afraid that she wouldn’t wake up if the
baby was awake and didn’t take it. She knew that
something was wrong because she couldn’t relax but
didn’t know what was happening. She was bathing
the baby and had a terrible image that came into her
head of putting the baby’s head under the water and
feared that she could be “just like Andrea Yates” and
decided that she needed to come to the ED for
assessment.