 Hi, everyone. I'm Dr. Thirvila, one of the adult psychiatrists at the Behavioral Health Old Bridge Medical Center. I'm also an assistant professor at Higginsack Mary Ann School of Medicine. Today we are going to talk about perinatal and postpartum depression. So before we start, I just wanted to talk a little bit about statistics of depression. Depression is one of the leading cause of disability, as we all know among adults in the United States. And the prevalence of depression, in general, among women is 3.2% higher than men, according to National Institute of Mental Health. In regards to depression during pregnancy, it's more common in women who give birth. About 10% of pregnant women and women who has just given birth experience depression according to World Health Organization. And it is estimated that women who discontinue medication during pregnancy, antidepressant medication during pregnancy are five times more likely to relapse as compared to women who continued their antidepressant medication during pregnancy. So a little bit about perinatal depression. It is defined as depression in pregnancy around childbirth or within the first year after childbirth. Some of the medical technologies that we come across, antinatal depression is nothing but women suffering from depression during her pregnancy. And postpartum depression is depression suffered by the women following childbirth. These are some of the diagnosis that a pregnant lady after childbirth usually might experience. These are postpartum blues, postpartum depression, and postpartum psychosis. We are going to talk about postpartum blues and depression today. So postpartum blues, most of the majority of the women suffer from this. About 50% to 85% of the women suffer from postpartum blues. It occurs during the first few weeks after delivery and usually peaks on 4th or 5th day. It may last for a few hours or can last for up to a few days. Usually the symptoms include feelings of sadness, tearfulness, they might complain about anxiety, irritability, or morbidity also. It results spontaneously within two weeks after delivery if these symptoms doesn't resolve. And if patient is having worsening of symptoms, not only these symptoms, some of the other depressive symptoms, then it needs an evaluation by a behavioral health specialist. So in regards to perinatal depression, it's usually underdiagnosed and under-treated. About 14% to 23% of pregnant women diagnosed with depression during pregnancy and among those, 35% to 40% are in low-income group and minority groups. And 30% of those pregnant or postpartum women who are diagnosed with depression after childbirth usually might have developed a depression even during pregnancy, which went undiagnosed and under-treated. So what are the risk factors associated with perinatal depression? So the risk factors could be if a pregnant lady had history of anxiety, history of depression, or any life stressors, or if the pregnant lady has lack of social support from the family or from the community, low-income status, single status, poor relationship quality with her family members. And if the pregnancy is unintended or unplanned, that can also lead to one of the risk factors for perinatal depression. And domestic violence, it is shown that 3% to 9% of the intimate partner violence can also cause perinatal depression. And smoking is one of the risk factors associated with perinatal depression. Now I'm going to talk a little bit about risk factors associated with postpartum depression. These are almost similar to perinatal depression risk factors, except for the last three, which is a traumatic birth experience in the past and during childbirth, preterm birth, or infant admission to NICU. And breastfeeding problems are also risk factors associated with postpartum depression. And I'm going to talk a little bit about the comorbid illnesses that can be present along with perinatal depression. Most commonly are the anxiety disorders, which are generalized anxiety disorder and panic disorder. It can also, a pregnant lady also can suffer from obsessive compulsive disorder or substance use along with perinatal depression. So what are the symptoms of both perinatal and postpartum depression? So the pregnant women or women who gave up to a child can experience depressed mood, loss of interest or pleasure in doing things, significant changes in weight, either weight gain or weight loss, changes in appetite, could be decreased appetite or increased appetite. Insomnia, which is a lack of sleep. And hypersomnia, sleeping too much. Psychomotor agitation or retardation. Fatigue or a loss of energy, feeling worthless, or having excessive guilt. Also having cognitive difficulties, like inability to focus and concentrate, or even it is hard for the women to make even simple decisions. And the last but the most important one is if the patient is having thoughts of death, suicide or died. So what happens if the perinatal depression goes untreated? It can cause poor self-care to the pregnant women. Malnutrition, that can lead to a lot of other complications in the infant, not complaints with the prenatal care. And usually these set of women might have higher rates of substance abuse. They also fail to recognize or report signs of labor. It might cause preterm delivery if untreated in a preeclampsia. Also can cause low birth rate. Small for gestational age. Can cause lower apcarse scores in the infant. Impaired bonding with the baby can lead to postpartum depression. Lower rates of breastfeeding can also cause relationship issues. Poor parenting, which includes increased fetal abuse or neonaticide and maternal suicide. So talking about suicide in perinatal and postpartum depression, it's one of the leading cause of maternal death in pregnant and postpartum women. Most common methods that are used are hanging, jumping, or falling. One in five postpartum deaths are caused by suicide. It is very much under-reported and under-researched. The high risk for suicide is mainly during 9 to 12 months after delivery. So what will be the effects of newborn if the perinatal depression is undiagnosed and uncreated? So it may impair the neurocognitive development of the baby, which can lead to cognitive delays, developmental delays in childhood. Babies may also develop emotional and behavior problems. They have few facial expressions. Less active, less attentive, can be very irritable. And also, as they grow older, they have high risk of developing depression too. And if we see the physiological markers, they tend to have increased cortisol levels and decreased dopamine and serotonin levels. So how do we screen pregnant women when they go to primary care settings or OBGYN settings? So the standard question that we usually administer to the pregnant women is PHQ-9 questionnaire and Edinburgh postnatal depression scale. How often do you have to administer these questionnaires to the pregnant women? So the first time should be on their first prenatal visit, at least once in the second trimester, at least once in the third trimester. And immediately after delivery at first postpartum visit, and then you have to screen again at 6 and 12 months, either in the OBGYN clinic or in primary care settings. So this is how PHQ-9 questionnaire looks like. It's a very simple questionnaire, consists of nine questions. It hardly takes five to 10 minutes for the patient to fill it. Usually this asks about all the symptoms of depression, such as little interest or pleasure in doing things, feeling down, depressed or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, feeling bad about yourself, trouble focusing and concentrating, either moving or speaking slowly, that other people could have noticed. And the most important one is having thoughts to be better off dead or having thoughts to hurt themselves. These are scored in four different categories, not at all, several days, more than half the days and nearly every day. This is Edinburgh postnatal depression scale. This is also administered in prenatal, antenatal and postnatal visits. It also consists of 10 questions. I'm not able to get the entire questionnaire, but this also takes maybe the maximum 10 minutes for the patient to complete the questionnaire. So how are these questionnaires scored? The PHQ-9 questionnaire is scored as 0 to 27, anywhere between 0 to 27 points. And how it is categorized is 0 to 4 is none or minimal depression, 5 to 9 is mild depression. When they score about 10 to 14, it's moderate depression and 15 to 19 is moderate to severe depression. And about 20 is severe depression. Same with the Edinburgh postnatal screening questionnaire. It has 10 questions. If the score is greater than 12, or if they have a formative answer on question 10, which is thoughts of harming themselves or having thoughts to be better off dead, then we have to intervene and give them resources to help them out. So how do you manage perinatal and postpartum depression? As per the screening question is, if they come under mild depression, usually we refer them to psychotherapy. If they have moderate to severe depression, usually, they are referred to a psychiatrist or a behavioral health specialist for medication treatment for medication treatment and psychotherapy. If the patient is suffering from severe depression, along with the medications, depending on the patient's severity, such as if patient is having, he's exhibiting psychotic features or patient is having thoughts to hurt themselves or thoughts to hurt the baby, or if the patient is unable to care for themselves and the baby, usually that warrants inpatient hospitalizations and depending on how they are progressing, sometimes electroconvulsive therapy as well. So what are the psychological interventions that we usually offer for mild symptoms of depression? So these are cognitive behavioral therapy which is very commonly used, otherwise called CBT, interpersonal therapy, mindful-based cognitive therapy and psychodynamic psychotherapy. And in regards to the medications, a lot of people have, they are a little bit skeptical about using medications during pregnancy, but as per the FDA, there is no significant increased risk for continental malformations when treating a pregnant lady during pregnancy around childbirth and after childbirth with the medications. So most common medications that we use are antidepressants which are SSRIs, SNRIs and tricyclic antidepressants, which are TCAs. We also use atypical antidepressants in patients who are unable to tolerate SSRIs or SNRIs. Monoamine oxidase inhibitors, we usually, we don't use them that often because of very limited research and also they have a lot of drug-food interactions as well as drug-drug interactions. So we usually do not use monoamine oxidase inhibitors. So there was an FDA warning before 2011 that SSRIs may cause persistent pulmonary hypertension in newborn that I think that was released in 2004, but FDA changed updated in December to 2011 that there is no sufficient evidence to conclude that SSRIs cause persistent pulmonary hypertension of the newborn, which is a rare heart and lung condition. So basically they recommended to treat depression during pregnancy as clinically appropriate. So what are the SSRIs that we commonly use in pregnant ladies? Fluoxetine, which is otherwise called Prozac. I'm giving both generic and the inner trade names. Cytolopram is otherwise called Celexa, Acetylopram, Lexapro, Cetrelin is otherwise called Soloft and Peroxetine, otherwise called Paxil. And if a patient is unable to tolerate SSRIs, we can also use SNRIs or if patient is diagnosed with depression or anxiety prior to their pregnancy, you can always continue the medications that they have been on, except for mono-MN oxidase inhibitors. And some of the SNRIs that we commonly used in pregnant patients are Vanilla-Faxine, which is otherwise called Afexor, is Vanilla-Faxine, otherwise called Pristate, Geoloxetine, also known as Simbalta. And Vanilla-Faxine has an extended release form, which is more commonly preferred compared to regular Vanilla-Faxine, as it can cause withdrawal symptoms. Other atypical antidepressants that we usually require, Velbutin, Velbutin has different forms, XL, SR, depending on how they are released in our system. And the other atypical antidepressant that we use is Metazepine, also known as Remeron, usually used, this medicine is used in pregnant patients who are having insomnia, sleep issues, are also having decreased appetite and unable to keep anything due to morning sickness, because this medicine tend to also help with the appetite. Other antidepressants are serotonin modulators, such as Trasidone, Nefazodone, Velazodone, and Vatioxetine. These can also be used in patients who are unable to tolerate SSRIs, SNRIs, and TCAs. These are some of the TCAs that we usually use in pregnant patients. Some of these can cause sedation, so usually not preferred by most of the, you know, psychiatrists, but these are very good medications for depression too. These are Amitripriline, Laval, Chloropramine, also known as Anaphronyl, Desipramine, also known as Nopramine, Doxamine, which is known as Cinequan, Nortriplein, Pamelaar, Triatmipramine, Cermontal, Nipramine, also known as Tofrenyl, Amoxapine, also known as Ascending. So in, during pregnancy, there are a lot of changes in a woman's body, right? There is increase in plasma volume, there are a lot of hormonal changes happening in each and every time you stir during pregnancy, also it also causes increases liver metabolism, thereby what happens is the medications are breaking down faster than usual during pregnancy. So as a result, if a patient is stabilized on a certain dose of a medication, like an SSRI or an SMRI prior to pregnancy, usually you might have to increase the dose due to, you know, break down of the medications faster than usual during pregnancy to receive the same effect as prior to pregnancy. And most of the people, patients have doubts whether they can breastfeed, you know, postpartum while they are on these medications. According to American Association of Pediatrics, you know, they recommend any drug which is passed through, passes to breast milk less than 10% is safe. So usually all the antidepressants pass, you know, when they are administered to a pregnant, sorry, postpartum, you know, women who have postpartum depression, less than 2% of maternal weight adjusted doses passes through breast milk. So as per the AAP, it is safe to be administered even after pregnancy, after childbirth during their postpartum period. So what are the first FDA-approved drugs in postpartum depression? These are Brexanolone or Zulreso. It is approved in 2019. It is an IV infusion, needs to be hospitalized for the medication to be administered. These are GABA modulators. Usually patient might have, you know, a lot of sedation. So after the treatment, patient is usually, the mother should be monitored so that, you know, they're not having too much sedation while they're taking care of their infants for either it could be breastfeeding or anything else to improve their bonding with the baby. Zulanolone or Zulresovay is a newer, you know, oral first approved postpartum, you know, depression drug. FDA approved in October of 2023. Very recently approved, not still available in the market, but most likely it might be available in the next, you know, couple of months. This is administered about, you know, anywhere between 40 to 50 milligrams daily for up to 14 days. There is something called neonatal adaptation syndrome. Usually, you know, this affects, you know, babies who are exposed to SSRIs during the pregnancy. Not many infants experience this, you know, these symptoms, about 25% of the infants exposed to SSRIs experience these, you know, symptoms. Usually those are, you know, a baby can be very chittery, restless, can be irritable, can have insomnia or somnolence and also might have feeding problems. Not to worry about this, usually, you know, symptoms are transient and they resolve spontaneously and we don't need to, you know, medicate them with SSRIs. Usually the approach is conservative approach, you know, nursing, grooming, pacifying and low stimulation environment usually helps the baby. All right, thank you.