​Kembara Xtra - Medicine - Postpartum Depression

​Kembara Xtra - Medicine - Postpartum Depression 
Introduction 
Major depressive disorder (MDD) that recurs or first manifests in the postpartum period may also affect fathers or mothers who have adopted children.
Postpartum depression (PPD) is similar to nonpregnancy depression (sleep disorders, anhedonia, psychomotor changes, etc.); it most frequently has its onset within the first 12 weeks postpartum but can occur within 1 year after delivery. It is distinct from postpartum "blues" (sadness and emotional lability), which are experienced by 30-70% of women and start and end within the first 10 days postpartum.

Incidence and prevalence in Epidemiology 

Incidence
During the postpartum period, 10–20% of women experience a fresh episode of serious or minor depression.

Prevalence > 50% of women with PPD have depression before becoming pregnant or during it.

As much as 19.2% of women experience depression within the first three months after giving birth.

Pathophysiology and Etiology 
May be linked to sensitivity to hormonal fluctuations, including those caused by estrogen, progesterone, and other gonad hormones, as well as neuroactive steroids, cytokines, hormones of the hypothalamic-pituitary-adrenal (HPA) axis, altered levels of fatty acids, oxytocin, and arginine vasopressin, and genetic and epigenetic factors. 
Multifactorial, with biological and genetic susceptibility for neurobiologic deficit, the destabilizing effects of hormone withdrawal at birth, inflammation, and psychosocial stressors.

Premenstrual dysphoria history, a familial history of depression, a history of MDD, or anxiety and depression when pregnant are risk factors.

Substance abuse, undesired or unexpected pregnancies, numerous psychosocial stressors, a lack of social support, and violence against intimate partners are all factors that can lead to poor pregnancy outcomes (preterm birth, stillbirth, neonatal mortality, and significant deformities).
Postpartum pain, sleep disturbance, and fatigue; young mothers; multiple deliveries; African Americans and Hispanics may have greater incidence of PPD; recent immigration status; a history of traumatic childhood events; a decision to reduce antidepressant use during pregnancy; and gestational diabetes.

Prevention 

For better detection, widespread screening during pregnancy and the first year following childbirth using validated rating scales.
The prevalence of depression in a particular population may be decreased by screening pregnant and postpartum women for depression. Evidence supports this claim. Although the evidence for pregnant women was less strong, it was consistent with that for postpartum women in terms of the advantages of screening, the advantages of therapy, and the accuracy of screening equipment.

In small randomized studies, psychotherapy and counseling, particularly those based on cognitive behavioral therapy (CBT) and interpersonal therapy (IPT)-based therapies, have been proven to be useful in preventing PPD in people at risk, but the USPSTF states that further study is required.

Sertraline is one SSRI that may be useful in preventing PPD in women who are at high risk for developing the condition.


Postpartum blues, dysthymic disorder, cyclothymic disorder, MDD, and depressive illness not otherwise defined are associated conditions.

Diagnoses include psychomotor agitation or retardation, suicidal ideation, diminished interest in once captivating or joyful activities, depression/poor mood, guilt, and low self-esteem. Other symptoms include changes in sleep, energy, attention, and food.


Multiple Diagnoses 
Baby blues: mood lability dissipates within days; it's not a psychological condition.
Postpartum psychosis: a serious mental health issue

Depression and anxiety following childbirth

Obsessive-compulsive disorder following childbirth and hypothyroidism
Depression may be a symptom of postpartum thyroiditis, which can affect up to 5.7% of patients in the United States.
 Depressive episode, bipolar disorder

Laboratory Results 

Initial examinations (lab, imaging)
There is no requirement for blood testing, however certain assessments based on the patient's history and symptoms may be made, such as a complete blood count (CBC), thyroid-stimulating hormone (TSH), and vitamin B12 level

Tests in the Future & Special Considerations
urine drug test, -hCG, and urine analysis

Other/Diagnostic Procedures
The Edinburgh Postnatal Depression Scale is a screening tool that has been approved.
The Patient Health Questionnaire-9 (PHQ-9) is a widely used screening instrument that has been validated.
The mother's partner should fill out the Edinburgh Postnatal Depression Scale (partner version) to get his or her perspective on the depression of the mother.

Management 

Identify any suicidal, homicidal, or infanticide-related ideas as well as any homicidal thoughts that may be present.
Check for psychotic signs including delusions and hallucinations.
Those who have suicidal, homicidal, or infanticide thoughts may need to be admitted right away.
When depressive symptoms are moderate to severe, strongly consider medication. Psychotherapy is often thought of as the first-line treatment for mild depressive episodes.
Pharmacotherapy combined with individual outpatient psychotherapy may be helpful.

First Line of Medicine
Antidepressant choices for non-breastfeeding women are similar to those for non-postpartum patients.
SSRIs are often efficient and secure. Using paroxetine while pregnant has been linked to fetal cardiac defects: - Fluoxetine (Prozac): 20 to 60 mg/day PO; sertraline (Zoloft): 50 to 200 mg/day
- Escitalopram (Lexapro): 10 to 20 mg/day PO; citalopram (Celexa): 20 to 40 mg/day PO; paroxetine (Paxil): 20 to 50 mg/day; PO given at bedtime; (related with a very tiny increase in risk of cardiovascular abnormalities with first trimester use);
SNRIs (inhibitors of serotonin-norepinephrine reuptake):
- Desvenlafaxine (Pristiq): 50 to 100 mg/day PO and venlafaxine (Effexor XR): 75 to 225 mg/day PO
- 60 to 120 mg of duloxetine (Cymbalta) orally daily
Non-traditional antidepressants:
- Bupropion (Wellbutrin): 150 to 450 mg/day PO (activating, no erectile dysfunction).
- Mirtazapine (Remeron): 15 to 45 mg/day PO at bedtime; (increases appetite and is sedative at lower doses, no sexual dysfunction) - Tricyclic antidepressants (TCAs), particularly nortriptyline, have been shown to be as effective as SSRIs, but are more lethal in overdose and have higher rates of unfavorable side effects.
75–150 mg of nortriptyline administered orally each day at bedtime 
Mood stabilizers are necessary for the treatment of bipolar disorder.
nursing mothers: Generally, taking antidepressants shouldn't interfere with nursing.
– SSRIs and a few other antidepressants are regarded as a safe choice when nursing.
– Although all antidepressants are secreted in breast milk, they are often safe for use during lactation. Sertraline and paroxetine are thought to be the drugs that work best with nursing because they have the lowest translactal transit. With venlafaxine, fluoxetine, and citalopram (5)[B], translactal transit is increased. Start with a modest dose and gradually increase it. Minimize polypharmacy. Make an effort to use just one psychotropic drug at a time. Check for negative side effects in the infant.
– To prevent subjecting the mother and child to the hazards of untreated PPD, it is preferable to continue an effective medication rather than switching antidepressants (5)[B].
– Women who are nursing need more information and assistance on the advantages and disadvantages of using antidepressants while nursing.
– Take into account the detrimental consequences of PPD on newborn and child development.
– whenever possible, discussions of the patient's and her partner's treatment options. Consider the patient's specific expectations and treatment choices, as well as her personal mental history, prior response to therapy, hazards of under or no treatment, information on the safety of drugs while nursing that is now accessible.
– Visit the following website for more details: https://www.ncbi.nlm.nih.gov/books/ NBK501922/?report=classic
Next Line
If the patient doesn't respond, you might want to try another antidepressant. In the case of PPD that is resistant to treatment, augmentation could be required. Depressed postpartum women who do not respond to antidepressant medications, have severe or psychotic symptoms, cannot tolerate antidepressant medications, are actively engaging in suicidal self-destructive behaviors, or have a prior history of responding to ECT may benefit from electroconvulsive therapy (ECT).

Issues for Referral Patients exhibiting psychotic symptoms should seek psychiatric evaluation.

If hallucinations or delusions are evident, hospitalization should be strongly considered right away. Hospitalization is also required if the mother's capacity to care for herself and/or her child is seriously impaired.

Furthermore Treated 

Psychoeducation, listening visits (nondirective counseling), and psychodynamic psychotherapy may also lessen PPD symptoms. Evidence-based therapies for PPD include CBT and IPT.
SURGICAL AND OTHER PROCEDURE
In March 2019, the FDA authorized brexanolone for PPD. It is a quickly acting antidepressant that is given intravenously continuously for 60 hours. Access to this drug is constrained. It is quite expensive and can only be administered at facilities that have signed up for the Risk Evaluation and Mitigation Strategy Program.
Think about women who reject or don't respond to ECT and have severe PPD.

Requires continuous pulse oximetry monitoring FDA advises that healthcare professionals check on patients at least every two hours for severe sedation and loss of consciousness.

Dry mouth, hot flashes or flushing, diarrhea, dyspepsia, excessive sedation, loss of consciousness, and dizziness are a few of the side effects.

Healthcare Alternatives 
newborn massage, newborn sleep interventions, exercise, and bright light treatment may be helpful. Breastfeeding has been linked to reduced stress and enhanced maternal happiness.

Admission Notice

For patients with persistent sadness or psychotic symptoms, seek psychiatric advice. Consider getting hospitalized right away if there are any hallucinations or delusions present. It is not advisable to leave the infant alone with the insane mother.
Suicidal or homicidal ideation, psychotic symptoms, thoughts of harming a baby, inability to care for oneself or an infant, and extreme weight loss are required for admission and initial stabilization. 
The mother must be able to care for herself and the child, and there must be no suicidal or homicidal ideas, psychotic symptoms, or thoughts of harming the unborn child.

Patient Follow-Up Monitoring
A collaborative care strategy that includes follow-ups with a case manager and visits to the doctor's office 
Consultation with the baby's pediatrician, especially if the mother is on psychiatric drugs and breastfeeding.

There is conflicting data to suggest the addition of a multivitamin with minerals and omega-3 fatty acids to a healthy diet, especially during breastfeeding.

Prognosis It has been demonstrated that treating maternal depression until it is in remission has a good effect on the mental health of children.
Some individuals, especially those with misdiagnosed or undertreated depression, may experience persistent depression that necessitates ongoing care.
Postpartum psychosis is linked to terrible consequences including maternal suicide and infanticide. Untreated maternal depression is linked to decreased mother-infant attachment and cognitive and linguistic development delay in babies and children.

Complications 

Preterm and low birth weight babies Suicide, self-harming behavior, psychosis Neglect of the baby, harm to the baby