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Update on Postnatal Depression Lee Tak Shing, Dominic MBChB!Hons", MD, MRCPsych, FHKAM, FHKCPsych PND Normal adjustment Transient & mild Understandable Blues Transient & mild PND 11# prevalence 6 wks pp 5000+ PND each year Persistent Dysfunctional Out of proportion Postpartum psychosis Voices, delusions Onset usu w/in 2 wks What is PND? Mood disorders Out of control: “malignant sadness” Persistent !>2 wks" Severe !# of symptoms" Functional impairment Textbook Symptoms Low mood, lack of enjoyment Lack of interest, lack of drive Lack of energy Insomnia Retardation Poor appetite, weight loss Impaired concentration Negative cognitions Suicidal ideas Local Symptoms Special Symptoms • Tearfulness • Irritability • Unexplained medical symptoms • Anger • Excessive worries of infant health • 悶 • Admissions with no medical diagnosis • 辛苦 Eliciting symptoms • Illness Experience Probing questions • • • • How do you sleep? How are you coping? Baby easy to look after? How was the zuoyue arranged? It is common to feel depressed and stressed in first few days. Have you ever had such experience? How to diagnose PPD? DSM criteria 5 symptoms x >=2 weeks + dysfunction Real life Persistent symptoms !day in, day out" Dysfunctional Loss of control !not my usual self" Distress Early morning wakening, retardation, or suicidal ideas Suicidal ideas !don’t panic!" 1. 2. 3. 4. Not worth living Vague, fleeting ideas Plan Action Risk Factors Gene x Environment interaction Lack of social support Poor marital relationship and spousal violence Concurrent life events Past hx of depression, esp. in postpartum Personality vulnerability Infertility Graves Disease Expatriats? 13-week BDI (mean, 95% CI) In$law is more important than husband Fewer PND for Women w Peiyue 14 12 10 8 6 4 2 others poor/very poor mother-in-law relationship Complications of PND 42# of HK PPD remained depressed at 2 years postpartum How to identify PPD? Sharpen clinical awareness Screening scale Maternal and paternal unemployment • Separation and divorce • Children emotional and behavioural disorder • Child abuse • Suicide Screening Scales • • • • Edinburgh Postnatal Depression Scale EPDS • 10 items on mood symptoms • past 7 days • no somatic items • one item on self harm ideas • 9/10 cut$o% for HK Chinese women • Item 1 & 3 reversely scored !" ___________ #$%&'()*+(CEPDS 2.1) ,- _________________________ ./ ________ 012345 ____________ 6+78 _____________________ 9:;<=>?1@23ABCD@EFG>HIJKLMNFOPQRS>TUVWIJHXYK Z[;\]^>_WHI`Aa^TUVWHIJKbc; BIdefK g1hijklmnK g2hop"klmnK g3h\qrmnK g4hFstujK MNXYg2h+:vwF4xyop"kz{IdefKL|}n~•€•‚Gƒ„K vT U VW x ; 1. }‚—FnK g1h o•˜klB{\Q™šK g2h uj‚—›œ•K g2h jklB\Q•žk›n™š!ŸK g3h ¡¢‚—£K g3h op"klB{Q•žk›n™š!ŸK g4h BF¥{Q™š!ŸK 5. 7. BŽ\Œ•A‚«¬-K g1h }‚—FnK g2 h uj‚—›œ•K g2h jklmnK ¡¢‚—£K g3h \qrmnK g4h FstujK g4h 4. €¤\QK B¦§8¨©“HFªK g3h 3. Ž•†•‘’Ba“A”B•\T–K g1h g4h 2. 6. BQ…d†‡jˆHF‰AŠ‹!Œ•K g1h €¤\QK 8. ®†•¯°kAB±\²³´µ¶·¸K op"klmnK BId¹Tº»¼K g1h op"klmnK g1h op"klmnK g2h jklmnK g2h ½®klmnK g3h \qrmnK g3h \qrmnK g4 h ujmnK g4h FstujK 9. B¾¿¾ÀIdÁºÕK B\Œ•dÄK g1h FstujK g1h op"klmnK g2h Å£jK g2h jklmnK g3h jklmnK g3h ]^zÆmnK g4h qrmnK g4h ujmnK 10. B¾¿¾ÀIdÇȺÉÊK BDT³¼Ç·¸K g1h ½®•klmnK g1h ½®•klmnK g2h jklmnK g2h jklmnK g3 h \qrmnK g3h Ž£mnK g4h FstujK g4h ujmnK Cox, J.L. Holden, J.M. and Sagovsky, R. (1987). Detection of postnatal depression. Lee, D.T., etal (1997) Detecting postnatal depression in Chinese. Antenatal depressive symptoms are best predictor of PPD Br. J. Psychiatry 150: 782-786. Br.J. Psychiatry 172: 433-437. Postnatal Depression is a Misnomer • Antenatal depressive symptomatology is one of the most powerful predictors of PND • Substantial proportion of postnatal depression begins in the pregnancy • Antenatal depression shared similar risk factors with postnatal depression • Perinatal depression rather than postnatal depression is a more accurate description of the psychopathology Epidemiology • • • • AN depression is associated with PND • Maternal neglect and poorer AN care • Alcoholism and drug abuse • Maternal anxiety increases uterine artery resistance • low risks, esp 2nd trimester Contemporary epidemiologic studies showed 10# $ 20# prevalence • Adverse consequences • Fallacy of protected pregnancy in traditional teachings US, UK, Australia, Japan, Portugal, Uganda Hormonal protection is a myth Adverse consequences • Growth retardation • Lower birth weight and born early • SGA • preclampsia • Inferior performance on neonatal behavioural assessment • Attention deficit and hyperactivity Higher rate of Caesarean section Risk Factors • past abortion, miscarriage, infertility • reject pregnancy and considered abortion • past depression or psychiatric history • medical history or complications • marital status, immigrants, education, employment, income, financial di&culties • poor social support, life events, marital discord • drug and alcohol abuse 6# of HK mothers have antenatal depression AN Depression Symptoms AN Depression assoc w more epidural, C$section, pre$ term, SGA, pre$eclampsia • Broken sleep !not related to nocturia" • Lack of appetite, poor weight gain • Irritability, poor temper, tearfulness • Depressed mood, anxiety, panic attacks • Negative thoughts, excessive worries !e.g. fetal malformation" • Atypical somatic symptoms Treatment • Antidepressants • Head$Start Programme • • Serotonin Selective Reuptake Inhibitor • Fluoxetine !Prozac", Sertraline !Zoloft", Escitalopram !Lexapro" • Paroxetine !Seroxat" $$$ fetal abnormality • STAR*D study SNRI • Venlafaxine, Mirtazepine Tricyclics • Amitriptyline, Nortriptyline !breast feeding" Treatment STAR*D Results: Unresolved Depression Symptoms More than 2/3 of patients had unresolved symptoms 67% STAR*D Study (N=2,876) 10 Mild symptoms !28% Remission !33% 9 8 Moderate symptoms !23% Severe symptoms Very severe symptoms !12% !4% • Antidepressants • 7 6 % 5 4 • 3 2 1 • 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Depressive symptoms (QIDS-SR score) after up to 12 wk antidepressant treatment Serotonin Selective Reuptake Inhibitor • Fluoxetine !Prozac", Sertraline !Zoloft", Escitalopram !Lexapro" • Paroxetine !Seroxat" $$$ fetal abnormality • STAR*D study SNRI • Venlafaxine, Mirtazepine, Duloxetine Tricyclics • Amitriptyline, Nortriptyline !breast feeding" Adapted from Trivedi MH, et al. Am J Psychiatry. 2006;163:28-40. Length of Randomized, Double-Blind, Placebo-Controlled Studies in Relapse and Recurrence Treatment 6 Months 1 Year 2 Years Venlafaxine XR1-3* ! ! ! Duloxetine4 ! Escitalopram5 ! Bupropion6 ! Sertraline7,8 ! ! † Paroxetine9 ! ! ‡ • Antidepressants • ! != demonstrated relapse/recurrence prevention at end point. • *In the venlafaxine XR study, patients had at least 3 prior episodes of depression in their lifetime. †Sertraline has been studied in 2-year recurrence prevention as monotherapy but failed to show a significant difference vs. placebo at end point. ‡Paroxetine has been studied in 2-year recurrence prevention in combination with psychotherapy/clinical management sessions with or without augmentation, but not as monotherapy. In patients with recurrent depression, no significant difference was seen between paroxetine and placebo. 1. 2. 3. 4. 5. 6. 7. 8. 9. • Simon JS, et al. J Psychiatr Res. 2004;38:249-257. Montgomery SA, et al. J Clin Psychiatry. 2004;65:328-336. Data on file, Wyeth Pharmaceuticals Inc. Detke MJ, et al. Eur Neuropsychopharm. 2004;14:457-470. Rapaport MH, et al. J Clin Psychiatry. 2004;65:44-49 Weihs KL, et al. Biol Psychiatry. 2002;51:753-761. Keller MB, et al. JAMA. 1998;280:1665-1672. Wilson KCM, et al. Br J Psychiatry. 2003;182:492-497. Reynolds CF, et al. N Engl J Med. 2006;354:1130-1138. Neonatal Withdrawal Syndrome Side E%ects • • • • • • • Serotonin Selective Reuptake Inhibitor • Fluoxetine !Prozac", Sertraline !Zoloft", Escitalopram !Lexapro" • Paroxetine !Seroxat" $$$ fetal abnormality • STAR*D study SNRI • Venlafaxine, Mirtazepine, Duloxetine Tricyclics • Amitriptyline, Nortriptyline !breast feeding" Nausea, insomnia, agitation, anxiety Warn and be sensitive about “sexual repulsiveness” No long term side e%ects Discontinuation syndrome !slow withdrawal" • Health Canada warning Aug 9 2004 • feeding and or breathing di&culties, seizures, muscle rigidity, jitteriness, constant crying • bupropion, citalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, venlafaxine • careful weighting of pros and cons is important 2 weeks onset !start treatment asap" Persistence !“investment”" Family supervision ORIGINAL CONTRIBUTION Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue Antidepressant Treatment SSRI in Pregnancy • Early pregnancy • • Lee S. Cohen, MD Lori L. Altshuler, MD Bernard L. Harlow, PhD Ruta Nonacs, MD, PhD D. Jeffrey Newport, MD Adele C. Viguera, MD Rita Suri, MD Vivien K. Burt, MD, PhD Victoria Hendrick, MD Alison M. Reminick, BA Ada Loughead, BA Allison F. Vitonis, BA Zachary N. Stowe, MD Ventricular septal defect P Pulmonary hypertension of the newborn • Neonatal withdrawal syndrome Objective To describe risk of relapse in pregnant women who discontinued antidepressant medication proximate to conception compared with those who maintained treatment with these medications. REGNANCY HAS HISTORICALLY been described as a time of emotional well-being, providing “protection” against psychiatric disorder.1,2 However, systematic data to support this impression are sparse. A prospective communitybased study described similar rates of depression in gravid and nongravid women3 and, more recently, a second study noted the persistence of depressive symptoms during pregnancy.4 The high risk of depressive relapse following discontinuation of maintenance antidepressant therapy in nongravid patients treated with antidepressants has been well established. 5 The determination of risk of relapse following discontinuation of antidepressants during pregnancy or in those women who maintain treatment with these medications during pregnancy has not been previously investigated. Cli- Late pregnancy • Context Pregnancy has historically been described as a time of emotional wellbeing, providing “protection” against psychiatric disorder. However, systematic delineation of risk of relapse in women who maintain or discontinue pharmacological treatment during pregnancy is necessary. Design, Setting, and Patients A prospective naturalistic investigation using longitudinal psychiatric assessments on a monthly basis across pregnancy; a survival analysis was conducted to determine time to relapse of depression during pregnancy. A total of 201 pregnant women were enrolled between March 1999 and April 2003 from 3 centers with specific expertise in the treatment of psychiatric illness during pregnancy. The cohort of women was recruited from (1) within the hospital clinics, (2) selfreferral via advertisements and community outreach detailing the study, and (3) direct referrals from the community. Participants were considered eligible if they (1) had a history of major depression prior to pregnancy, (2) were less than 16 weeks’ gestation, (3) were euthymic for at least 3 months prior to their last menstrual period, and (4) were currently or recently (!12 weeks prior to last menstrual period) receiving antidepressant treatment. Of the 201 participants, 13 miscarried, 5 electively terminated their pregnancy, 12 were lost to follow-up prior to completion of pregnancy, and 8 chose to discontinue participation in the study. Main Outcome Measure Relapse of major depression defined as fulfilling Structured Clinical Interview for DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] Diagnosis (SCID) criteria. Results Among the 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Among the 82 women who maintained their medication throughout their pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication. Women who discontinued medication relapsed significantly more frequently over the course of their pregnancy compared with women who maintained their medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P!.001). Conclusions Pregnancy is not “protective” with respect to risk of relapse of major depression. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation. nicians need such information to collaborate effectively with patients to tailor careful risk-benefit assessments with regard to antidepressant drug use for ©2006 American Medical Association. All rights reserved. Management • Antidepressants Vs. Psychotherapy • Balance the risk between • Fetal safety: teratogenicty and neurobehavioral toxicity • Suicidal risk and adverse physical e%ects of depression • Speedy recovery www.jama.com JAMA. 2006;295:499-507 Author Affiliations are listed at the end of this article. Corresponding Author: Lee S. Cohen, MD, Perinatal and Reproductive Psychiatry Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital, WACC 812, 15 Parkman St, Boston, MA 02114 ([email protected]). (Reprinted) JAMA, February 1, 2006—Vol 295, No. 5 499 Treatment • Psychosocial • Marital counselling !most husbands are just ignorant", in$law conflicts • Maid, letters, CSSA, rehousing, … • Sick leaves