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Perinatal Mood & Anxiety Disorders:

What ALL Clinicians Need To Know

Gabrielle Mauren, PhD, LP, PMH-C

Minnesota Psychological Association

First Friday Forum

January 7, 2022

Disclosures

▪ Disclosure of Financial Relationships: I am employed by Park Nicollet Health Services (Minnesota, USA).

▪ I have co-authored a book on PMADs – “Myself Again: The PARENTS Postpartum Survival Guide” (Praeclarus Press, 2021).

▪ I have not accepted any reimbursement (financial, gifts, or in-kind exchange) for this presentation from any source other than the accredited CE provider or its educational partner (or fiscal agent).

Objectives

1. Recognize the symptoms and diagnostic differentials for the

range of Perinatal Mood and Anxiety Disorders, (e.g., baby

blues, depression, anxiety, trauma, and psychosis).

2. Describe risk and contributing factors for developing

Perinatal Mood and Anxiety Disorders.

3. Explain the treatment options for Perinatal Mood and Anxiety

Disorders, including empirically supported psychotherapy

models.

PMADs: The Basics

Perinatal Mood & Anxiety Disorders

(“PMADs”)

Mood Disorders(depression, bipolar disorders, postpartum blues, etc.)

Anxiety Disorders(panic, generalized anxiety, OCD, PTSD, etc.)

Psychosis(schizophrenia, mania, depression, etc.)

About PMADs (U.S. estimates)

• 70-80% of new mothers will experience the baby blues

• 15-20% will experience perinatal depression

• 10-25% will develop an anxiety disorder

• 0.1-0.2% will develop postpartum psychosis(PSI, 2021)

• Of all women who will experience depression in their lifetimes, 50% will have their first episode after having a baby. (APA, 2021)

• When do symptoms present?

• Anytime within the first 12 months, often in the first 2-4 months postpartum, sometimes during pregnancy.

What is the Risk of Developing PMADs?

Like most mental health conditions, a previous history of psychiatric illness

increases risk for developing PMADs.

• No history of psychiatric illness: 10-20%

• History of major depression: 25%

• History of depression during pregnancy: 35+%

• History of bipolar disorder or perinatal depression: • 23+% if meds continued• 66+% if off meds• 17+% will be severe illness

• History of postpartum psychosis: • 30-90%• 29+% will be severe illness

Several Factors May Increase Risk of PMADs

• Past psychiatric illness

• Depression during pregnancy • A very strong predictor of

postpartum depression

• Early postpartum (first 3 months)

• Pregnancy complications • Pre-eclampsia• Hyperemesis gravidarum• Gestational diabetes• Pre-term birth• C-section delivery• Fetal distress• Postpartum hemorrhage

• Socioeconomic stress

• Younger age of mother

• Limited social supports

• Breastfeeding challenges

• Colic in the newborn

Causes of PMADs

Physical changes such as a dramatic drop in progesterone, thyroid dysregulation, changes in blood volume and pressure, changes in metabolism and immune functioning may all contribute to mood changes.

Emotional factors such as anxiety about caring for the newborn, sleep deprivation, a sense of loss of control, or a struggle with one’s sense of individual identity, also may contribute to depression and anxiety.

Environmental factors such as a colicky baby or “demanding” older child, financial problems, difficulty with breastfeeding, relationship problems, or other stressors may play a causal role.

Discontinuation of an antidepressant during or just prior to pregnancy increases the risk of PMADs. Up to 68% of women who stop medication will relapse, many within a few weeks. (Cohen, et al., 2006)

Physical Changes

Environmental Factors

Emotional Factors

PMADs Screening Recommendations

The American Congress of Obstetricians & Gynecologists (ACOG) & Postpartum Support International (PSI) suggest the following guidelines for screening:

• At 1st prenatal visit

• At least once in 2nd trimester

• At least once in 3rd trimester

• At 6-week postpartum obstetrical visit (or first postpartum visit)

• Repeated screening at 6 & 12 months in OB/primary care settings

• At 3, 9, & 12 month pediatric visits

The PHQ9 and EPDS are validated

instruments for use with a perinatal

population.

Early Identification is Key!

Who sees these patients?

OBGYNs, Midwives – prenatal and 6-week postpartum visits

Pediatricians, Family Physicians – well-baby visits

Nurses – clinic phone calls or home visits

Doulas – prenatal or postpartum home visits

Lactation Consultants – in hospital or at home

Diagnosis & Assessment

The Baby Blues

The Baby Blues are characterized by mild, transient

symptoms of depression/anxiety with no impairment

in functioning. It occurs during the first 2 weeks

postpartum in up to 80% of women, (PSI, 2021).

Symptoms tend to peak around the 4th or 5th day &

gradually remit on their own.

The Baby Blues do not indicate pathology & no

formal treatment is needed other than family support.

Severe blues can be difficult to distinguish from early

signs of postpartum depression or psychosis.

Typical Symptoms:

• Mood reactivity

• Irritability

• Anxiety

• Tearfulness

• Trouble sleeping

• Poor concentration

• Easily overwhelmed

Perinatal Depression

Perinatal Depression is much more serious than the

Baby Blues because it impairs the mother’s

functioning (her ability to care for herself, the baby and

other children and/or to perform other daily tasks).

It affects approximately 15% of women, (PSI, 2021).

Symptoms typically begin 2 weeks to 4 months after

delivery.

🠶 However, some women (for reasons unknown) have a delayed onset – so symptoms can occur

any time within the first year.

Typical Symptoms:

• Intense irritability, anger, or mood

swings

• Sad mood

• Crying spells

• Insomnia

• Loss of appetite or overeating

• Overwhelming fatigue

• Loss of interest

• Difficulty making simple decisions

• Withdrawal from family & friends

• Guilt & negative thoughts about her

mothering

• Ambivalent or negative thoughts

towards the baby

• Thoughts of harming herself or the

baby

Perinatal Anxiety

10-22% of women will experience Perinatal Anxiety, which can manifest as obsessive thinking, excessive worries, panic attacks, severe insomnia, distorted thinking, and/or intrusive thoughts. (PSI, 2018)

Intrusive Thoughts/Postpartum OCD: scary thoughts about the baby’s safety or images of harming the baby.

• These should be assessed thoroughly, but in most cases, they do not indicate that the baby is unsafe or that the mother is at risk for following through with the thoughts.

• 40% or more of mothers with PPD or PPA report having these types of thoughts. (Kleinman & Wenzel, 2010)

• Women are often ashamed of these thoughts or worried that child protective services will become involved if she reveals them to someone.

With PPA, the woman’s mood is not necessarily low or depressed & thus her symptoms are often not picked up on screening tools.

Typical Anxiety Symptoms:

• Racing, ruminative

thoughts

• Inability to relax

• Poor sleep

• Fatigue

• Irritability

• Excessive worry

• Excessive checking on

baby

Common Themes of Intrusive

Thoughts:

• The baby dying in its sleep

• Harming the child with a knife

or by shaking

• Accidents or mistakes leading

to injury or death

• Sexual misconduct involving

the child

• Contamination

BIPOC Moms are at a Higher Risk for PMADs

• Studies find that BIPOC

women have a 2x+ higher

rate than white women, (Howell et

al., 2005) and they are half as like

to receive treatment (Kozhimannil, et al., 2011).

• Many of these disparities

persist after controlling for

maternal educational

attainment, income, marital

status, and other measures of

socioeconomic status.

A multi-factorial problem:

• Socioeconomic disparities (lower income,

disparities in education and employment)

• Lack of insurance coverage and health

conditions during pregnancy increase risk

• Limited access to mental health care

• Hesitation to obtain MH treatment due to past

poor experiences/poor care received

• Cultural expectations around mental health

and asking for help

• Avoidance of medical care due to feelings of

embarrassment, shame, stigma

PMADs in New Fathers, Partners, and

Non-birth Parents

• 1 in 10 new fathers will suffer from Paternal Postnatal Depression

(PPND). (PSI, 2021)

• When mom has PPD, there is a 50% chance that dad will also develop

depression.

• Non-birth parents & adoptive parents can also struggle with depression &

anxiety after bringing home a new baby. (Mott, et al., 2011)

• Depression & anxiety in these groups are often the result of feelings of

incompetence in their new role.

• “Maternal gatekeeping” may be a contributing factor.

Postnatal Depression Looks Different in Men

• Increased anger & conflict with others or

being easily stressed

• Increased use of alcohol or other drugs,

including prescription medication

• Frustration or irritability

• Violent behavior

• Losing/gaining weight

• Isolation from family & friends

• Impulsiveness & taking risks, like reckless

driving & extramarital sex

• Feeling discouraged

Paternal Postnatal Depression (PPND)

• Increases in complaints about physical

problems, like headaches, digestion

problems, or pain

• Problems with concentration & motivation

• Loss of interest in work, hobbies & sex

• Working more or spending more time

outside of the home

• Fatigue

• Experiencing conflict between how you

think you should be as a man & how you

actually are

• Thoughts of suicide

The bottom line…

Perinatal depression and anxiety are

the result of a huge life transition.

…It’s not just about hormones.

Postpartum Psychosis

Postpartum Psychosis is an acute, severe

illness occurring in 1-2 women/1,000 births (PSI,

2021).

• It is notable for its abrupt onset; 1/3 of women

have symptoms by postpartum day 3.

• Thoughts or attempts to harm baby or self are

often relayed as thoughts that the baby would

be “better off” dead or if mom was not around.

• These thoughts may be due to religious

delusions, the mother’s belief that she is

incapable, or that the baby is “defective.”

Typical Symptoms:

• Confused & disorganized

thoughts

• Extreme mood lability

• Insomnia

• Paranoia

• Hallucinations & delusions

• Thoughts of, or attempts to,

harm self or baby

Differentiating OCD from Psychosis

Postpartum OCD

• Thoughts are ego-dystonic

• Distressed by thoughts

• Avoid objects/triggers or being with their newborn

• Very common

• Minimal risk of harm to baby

Postpartum Psychosis

• Thoughts are ego-syntonic

• May not be distressed by thoughts

• May not show avoidant behaviors

• Uncommon

• High risk of harm to baby

Postpartum psychosis is a PSYCHIATRIC EMERGENCY &

requires immediate assessment by a qualified mental health

professional.

In one study, up to 5% of PPP women committed suicide & 4%

committed infanticide. (Friedman & Resnick, 2007)

Most women (72-80%) with postpartum psychosis have

psychosis as a feature of bipolar disorder or schizoaffective

disorder.

Postpartum PTSD

Approximately 9-17% of

women experience

Postpartum PTSD following

childbirth (PSI, 2018, Shaban et al., 2013).

Symptoms are those typical for PTSD:

1. intrusive distressing memories/dreams of

the event

2. dissociative reactions

3. avoidance

4. feelings of detachment or estrangement

from others

5. inability to remember important aspect of

the event

6. distorted cognitions that lead the person to

blame themselves or others for the event

7. irritable behavior and angry outbursts (with

little or no provocation)

8. hypervigilance

9. exaggerated startle response

10. sleep disturbance

What is Traumatic Childbirth?

Traumatic childbirth is often overlooked so there is a shortage of

information. Some reports indicate that up to 34% of women

report having a traumatic birth, with some symptoms of PTSD,

even if they don’t meet full diagnostic criteria. And the rates are

even higher for high-risk mothers. (Beck, Watson Driscoll & Watson, 2013)

“…an event occurring during the labor and delivery process that

involved actual or threatened serious injury or death to the

mother or her infant. The birthing woman experiences intense

fear, helplessness, loss of control and horror.” (Beck, 2004)

Factors Contributing to Postpartum PTSD

Previous history of PTSD or exposure to traumatic events.

Women who have experienced a previous trauma, such as rape or sexual abuse, are at a higher risk for experiencing postpartum PTSD.

A complicated birth (for baby or birthing person). For example:

Prolapsed cord

Unplanned C-section

Use of vacuum extractor or forceps

Baby going to NICU/Special Care Nursery

Severe physical complication or injury (e.g., severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, or perineal trauma)

Feelings of powerlessness, poor communication, or lack of support/reassurance during the delivery.

In the eye of the beholder…

• Trauma, and particularly traumatic childbirth, must be viewed

through the patient’s perspective.

• What will be traumatic to one patient, will not to

another.

• What would be considered a successful L&D to the

medical professional, could be traumatic to the

patient.

What about Partners/Dads/Non-Birth Parents?

• Fear or terror for the laboring person and infant

• Lack of control, helplessness

• Anger, resentment, feeling cheated

• Witnessing medical procedures being performed on laboring

person or baby

• Poor or missing communication from medical staff

• If birthing person has been diagnosed with PTSD, high

likelihood that partner/dad/non-birth parent will be too.

Functional Analysis for PMADs

Ask about:

• When and how the baby was born

• Daily mood

• Depressed mood often characterized by feeling empty, disengaged, uninterested in the baby….but not always

• Anxious mood can be characterized by irritability, impatience, moodiness OR excessive worry about the baby

• Whether they have an adequate support system

• Feeding/nursing/breastfeeding

• Daily activities and parenting

• Sleep (can they sleep when given the opportunity?)

• Feelings of being overwhelmed,

helpless, hopeless

• Poor appetite often presents as a

lack of interest in food, or feeling

overwhelmed (“I can’t find time to eat”)

• Thoughts of suicide

• Thoughts of violence

• Violence or abuse in the home

Organic Etiologies &

Neurobiological Considerations

Ruling Out Organic Etiologies

The differential diagnosis of PMADs should include possible organic causes of the symptoms. A medical assessment should be undertaken if indicated, to rule out organic etiologies such as:

• Postpartum thyroiditis (thyroid inflammation)

• Sheehan’s Syndrome (pituitary gland necrosis)

• Intoxication/withdrawal states

• Pregnancy-related autoimmune disorders (autoimmune encephalitis)

How Pregnancy Changes the Brain

• Very new, burgeoning area within neuroscience

• Reproductive hormones may ready a woman’s brain for the demands of

motherhood—helping her become less rattled by stress and more

attuned to her baby’s needs (Glynn & Sandman, 2011; Hoekzema et al., 2017)

• This brain remodeling persists for at least two years after baby is born

• May account for why moms wake up when the baby stirs while dads

remain asleep

• Fetal movement (even when the mother is unaware of it) raises her heart

rate and her skin conductivity, which are signals of emotion

• May be evidence of prenatal preparation for mother-child bonding

• When women look at photos of their infants, the areas of the brain

related to social cognition and theory of mind are activated (and show

evidence of significant changes in gray matter) (Hoekzema et al., 2017)

• Theory of Mind – helps us think about what is going on in someone

else’s mind

• Loss of grey matter not all bad – it’s “fine-tuning of connections”

• Like in puberty when pruning occurs of neural connections that

are no longer needed

• Fetal cells pass through the placenta into the mother’s bloodstream

• Those cells may be attracted to certain regions in the brain involved in optimizing maternal behavior

• Research supports the concept of “Mommy Brain”

• Forgetfulness is not just due to sleep deprivation – it’s these anatomical and physiological brain changes

• Limitations to this research:

• Thus far, mostly rodent studies – not yet clear how results generalize to humans

Brain Changes in Fathers

• Increased grey matter volume in several regions of the fathers’ brains.

• This includes areas previously identified as showing growth in new mothers,

• the striatum (involved in reward processing, among other functions)

• hypothalamus (hormonal control)

• amygdala and anterior cingulate cortex (involved in emotional processing)

• the lateral prefrontal cortex (involved in memory and decision making) (Kim et al., 2014)

• Some areas show reduced grey matter

• Like mother, this is a “shift of resources” away from the default network, and to the parts of the brain that enhance the father’s new vigilance for their offspring

• Dads who are their children’s primary caregivers show the kind

of activation in emotional processing seen mostly in primary

caregiver moms.

• This suggests there’s a parenting-brain network common to

both sexes.

• Like mom, new dads experience an increase in the hormones

estrogen, oxytocin, prolactin, and glucocorticoids. (Abraham, et al., 2014; Benedetta, L., Glasper, E.R., & Gould, 2010)

• Human dads show a decrease in testosterone, which is

hypothesized to make dads less aggressive and bring them

closer to their children.

• “Maternal instinct” makes moms incredibly good at picking out

their baby’s unique cry – research has found that dads are just

as good as moms.

Risks Associated with Untreated PMADs

Risks Associated with Untreated PMADs (during pregnancy)

• Poorer adherence to OB care

• Poor self-care

• Poor nutrition

• Poor sleep

• Depression relapse with med discontinuation (68%)

• Bipolar relapse with med discontinuation (>70% total may relapse, with 50% relapsing within 2 weeks)

• Increased risky behaviors in mania

• Higher rates of drug, alcohol, and tobacco use during pregnancy

• Pre-term birth

• Possible mechanism:

depression dysregulates HPA

axis, leads to increased

corticosteroid production,

potentially reducing umbilical

blood flow, leading to hypoxia

and preterm birth

• Low birth weight

• Pre-eclampsia

• Decreased fetal heart rate

responsivity

• Impaired fetal growth

• Higher rates of gestational diabetes

Risks Associated with Untreated PMADs

• Exposure to psychiatric disorders, stress, and hypothalamic-

pituitary-adrenal-axis (HPA axis) dysregulation can affect the

fetoplacental unit

• Symptoms of HPA axis dysregulation include: fatigue, sleep

problems, low libido, brain fog, weakened immune function,

and lower stress tolerance

Through this mechanism, psychiatric disorders and chronic stress

may impact long-term behavioral outcomes

HPA dysregulation is a toxic exposure

Maternal stress or depression

Dysregulation of HPA axis

Early labor, decreased birth

weight, increased reactivity to stress, fetal brain structural

changes

Risks Associated with Untreated PMADs(after delivery)Parent

• Untreated antenatal illness is a risk

factor for postpartum depression

• Less success with breastfeeding

• More postpartum complications

• Difficulty with bonding/attachment

• leading to insecure attachments and

moms who are less responsive and

sensitive to their children

• Poorer adherence to sound safety

and discipline practices (back

sleeping, baby gates, TV time,

spanking, etc.)

Child

• Effects on fetal genes that regulate

glucocorticoid receptors (stress

response)

• Changes in grey and white matter in

children• Fewer neural connections

• Babies with more difficult temperaments

• Poorer sleep (quality & duration)• a pattern persisted through 30 weeks

following delivery

• More negative affect, poor affect

regulation, less cooperation, and poorer

cognitive and language skills

• Higher rate of developmental delays by

18 mos

• Higher rates of later psychiatric illness in

the child

Risks Associated with Untreated PMADs(by developmental age)

Infants: colic, less vocalizing, less exploration

Toddlers: insecure attachment, lower self-esteem, aggression, motor delays

Preschoolers: anxiety, aggression, behavioral problems, deficits in cognitive

development

School age: aggression, anger, poorer cognitive processing, sleep problems,

anxiety, ADHD

Teens: conflicts with family/peers, depression, school problems, anxiety

Risks Associated with Untreated PMADs

• Suicide

• Lifetime suicide risk with major depressive disorder is 7% for men and

1% for women.

• Suicide accounts for up to 20% of postpartum deaths and may be the

second most common cause of mortality in postpartum women.

• Infanticide

• The rate of homicide of infants up to 1 year of age is 8 per 100,000 in

the United States

• Much more commonly associated with postpartum psychosis than with

depression or anxiety

Adverse Childhood Experiences (ACEs)

ACEs are potentially traumatic events that occur in childhood (birth to 17 years old).

Many studies show that ACEs are

linked to:

• Chronic health problems,

mental illness, &

substance use problems

in adulthood.

• ACEs negatively affect

education, job

opportunities, and earning

potential.

• Approximately 60% of adults surveyed across 25 states

reported that they have experienced at least one type of ACE.

• Nearly 1 in 6 reported they have experienced 4+ types of

ACEs.

PMADs Treatment Options

Medications

Medication Fundamentals

• People with mental illnesses deserve high-quality treatment

• Every baby deserves a healthy mother

• Mental illnesses AND/OR medications used to treat them may each pose risks to mother and child

• No single study tells the whole story

• We need to provide a balanced view of risks and benefits

• The relative importance of various risks and benefits will be different for each patient

• Treatment decisions may be very different for each individual

• Trust and a good working relationship between patient and clinician are critical for this decision-making

Risk/Benefit Balance

• There is no 100% risk-free zone

• We weigh the risks of untreated illness against the risks of medical treatment

What are the potential concerns about medications in pregnancy?

• Early pregnancy: teratogenicity (birth defects)

• Later pregnancy: further growth/development

• Labor & Delivery: neonatal toxicity and withdrawal, complications of labor

• Long-term effects: cognitive, motor, speech, social, emotional development in the child

Risk Considerations for Medications in Pregnancy

• The Real Risk• 2-4% of newborns will have a malformation

• 9% of those are due to maternal medical conditions • 20-25% due to a genetic etiology• 65% of unknown origin• Fewer than 1% of malformations are due to drug

exposures

• The Perceived Risk• Pregnant women given a medication not considered to be

teratogenic believed their risks of malformations was 24%

Risk Considerations for Medications in Pregnancy

• Relative vs absolute risk

• For example:

• 3.5x increased risk (sounds scary!) = 0.2% risk increases to 0.7% (not so scary)

• Baseline population risks

• 2-4% of newborns in the general population have a birth defect

• Timing

• Risks for birth defects are much lower as pregnancy progresses

BLUE BARS= highly sensitive periods of development when major defects might be produced

AQUA BARS= stages less sensitive to teratogens when minor defects may be induced

Moore and Persaud. The Developing Human: Clinically Oriented Embryology. 1999

Sources of Information

We don’t have:Prospective randomized double-blind placebo-controlled trials in pregnancy

We do have:

Non-randomized prospective trials

Retrospective case-control studies

Databases and registries (drug companies, governments, insurers)

Animal studies

Antidepressants are some of the best-studied medications in pregnancy (>40,000 exposures in the literature)

Confounding variables that may affect study outcomes

• Other medications (prescribed and OTC)• Illicit drugs• Alcohol• Tobacco• Environmental toxins• Socioeconomic status• Stress• Inflammation• Method of delivery• Gestational age at birth• Nutrition• Genetics/heredity• Effect of the mental illness itself = confounding by

indication

Take Aways on Medications

• There is a large body of research that indicates that antidepressants are safe during pregnancy & lactation. (MGH Center for Women’s Health, 2018)

• Patients should never go off their psychiatric medications “cold turkey.”

• Exception…Depakote which needs an urgent plan.

• Yes – there are risks (as there are with any medication). However, we must weigh the risks-benefits of untreated depression & anxiety, which we know have prenatal & long-term consequences to parent & baby.

• Encourage parents not to make decisions based on what they read on the internet, or have heard from a friend, & instead consult their care provider.

Psychotherapy

Psychotherapy

• Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are empirically supported treatments for PMADs

• CBT: challenging negative and irrational thinking

• IPT: improving interpersonal relationships, role transitions, communication

Key themes that often arise in therapy:

• Feeling overwhelmed and incapable

• Changing identity and role transitions

• Frustration and anger towards a partner who isn’t helping as much needed

• Feeling guilty about asking for help

• Social isolation

• Worries about making the “wrong” decisions for the baby

• Anxieties about a chaotic or traumatic birth experience

Clinical Pearls

Listen for:

• “I don’t feel like my usual self.”

• “I’m not doing a good job.”

• “I’m so tired but I can’t sleep.”

• “I have no one to help me.”

• “This isn’t what I expected.”

• Difficulty with feeding (breast or bottle) and/or worries about

baby’s weight gain

Ask: “How are you coping?” (not “How are you doing?”)

Resources & References

Interested in Learning More?

Postpartum Support International offers:

2-day certificate training in PMADs – offered many

times throughout the year

www.postpartum.net/professionals/trainings-

events/psi-certificate-training/

Advanced/ongoing training & certification

www.postpartum.net/professionals/certification/

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