Perinatal Mental Health History

History of Perinatal Mental Health and PSI Foundation:

• PSI was established in 1987.
• Jane Honikman founded PSI.
• Individuals and organizations in a global network increase resources and awareness of mental health related to childbearing.

1980s-1990s:

• PSI stands for Postpartum Support International, and DAD refers to Depression After Delivery.
• Advocacy groups emerged, empowering women and sparking social support movements.
• In 1994, the DSM-IV included a specifier for postpartum onset.

PSI statement on Social Support (June 2001):

• Social support ensures the mental health of women, men, children, and families during pregnancy and postpartum.

PSI Mission Statement:

• PSI aims to promote awareness, prevention, and parental mental health treatment related to childbearing worldwide.
• PSI is the only worldwide organization representing social support networks that plays a significant role in preventing and treating parental mental health issues.
• Its members span over 40 countries, including professionals and social support groups.

Objectives of PSI:

• Focuses on mental health awareness during the perinatal period.
• Supports parents and families, fostering collaboration and partnerships.
• Advocates for public policy and provides education and training.

PSI Memorial Quilt:

• Launched in 2002, honors women and children who died due to postpartum mood disorders and was created by Nancy Roberts.
• A second memorial quilt was revealed at the 30th annual PSI conference in July 2017.

PSI Programming Over Time:

• Includes a national psychiatric consult line and a perinatal mental health alliance for people of color.
• State chapters operate as 501C organizations, providing a peer mentor program and legal resources alongside national advocacy and international certification programs.

Mind The Gap:

• PSI leads a national initiative presenting a roadmap of priorities and actions to improve perinatal mental health.

The PMH-C:

• PMH-C offers a structure for professional development and standardized training to inform families about perinatal mental health specialists.

Terminology:

• Perinatal Period: Time from conception through the first year after birth, accounting for risks and hormone fluctuations.
• Prenatal/Antenatal: During pregnancy.
• Postpartum/Postnatal: The first year after giving birth.

PMAD:

• Encompasses perinatal mood conditions, including depression, bipolar disorder, and psychosis, as well as anxiety disorders like GAD, panic disorder, OCD, and PTSD.
• These disorders can interfere with daily functioning.
• Over 400,000 infants are born to depressed mothers each year in America, yet perinatal depression is the most underdiagnosed obstetric complication.

Prevalence of PMADs:

• Impacts 1 in 5-7 women and 1 in 10 men.

Common Maternal Health Screening:

• Gestational hypertension: 6-8%.
• Pre-eclampsia: 6-8%.
• Gestational diabetes: 6%. PMADs: 21%.

Cost of Untreated PMADs:

• Postpartum depression increases medical costs, inappropriate care, child abuse, neglects, and family dysfunction, affecting early brain development.

Risks of Untreated PMADs:

• Causes relationship problems, poor adherence to medical care, and exacerbates pre-existing medical conditions.
• Increases risk of interpersonal violence, separation/divorce, loss of financial resources, disability/unemployment, child neglect/abuse, developmental delays, and substance use.
• Can even lead to infanticide, homicide, or suicide.

Assumptions of Pregnancy:

• All pregnancies are planned, wanted, result in live baby.
• Live baby means love in relationship.
• Healthy baby means fulfillment.

Assumptions About Labor and Delivery:

• Strong women don't need medications.
• Natural birth is only good birth.
• C-section birth is taking easy way out and if had c-section means failed.
• Instantly bond with newborn.

Assumptions About Motherhood:

• Being a mother is instinctual and Breastfeeding is easy/natural and Mother will have time for herself.
• Good mothers do not take/need breaks.
• She doesn't need anyone as baby will sleep all the time.
• She is superwoman, partner, or mother.

Assumptions About Partners/Fathers:

• They are the rock, holding mother's hand, we are babysitters and don't know what to do being checked on by the lead parent.

Theories of Etiology

• Focuses on biological sensitivities to hormonal changes and the roles of estrogen and progesterone in pregnancy
• Highlights the importance of oxytocin and prolactin at birth, as well as women's moods

Endocrine Dysfunction

• Diabetes, history of thyroid imbalance, and fertility challenges

Significant Mood Reactions to Hormonal Changes

• Puberty, PMS, Hormonal birth control, Abrupt discontinuation of breastfeeding and Physical pain/inflamation

Etiology- Psychosocial

• Vulnerability- sleep, genetic predisposition and Relationships with own mother, ambivalence to parenthood Social/Environmental- history of trauma, poor social supports, institutional/structural racism.

Evidence of Psychosocial Risk Factors

• Family/personal history of previous MDAs, mood disorders, childhood sexual abuse

Exacerbtating psychosocial risk factors for PMADS

• Inadequate partner support, interpersonal violence
• Financial stress and childcare stressors

Stressors

• Recent loss/move, barriers to care and institutional racism, climate stressors, seasonal depression/mania
• Health challenges, temperament of the baby, returning to work, unresolved grief/loss

Prevalence of PPD in BIPOC Communities

• Black women experiences a higher percentage of PPPD, has not been studied well.
• Hispanic women also experience depressive symptoms, and PPD impacts Asian American women.

PMADs Within a Cultural Context

• Mothers may conceptualize, explain, and report depression symptoms differently.
• May not seek help due to fear or feeling unable to do so and the mothers maybe expected to fulfill one's social role.

Variability of Rate

• Cultural context of inventories and used cutoffs for screening.

Landmark Study of 10,000 US Mothers

• A study at a women's hospital screened women during the first year postpartum. Postpartum depression was found had depression during the 1st year of postpartum.
• Majority had primary diagnosis of unipolar depression with the most were diagnosed with bipolar.

Prenatal Depression Relapse

• 26% who continued medication relapsed during pregnancy but, 68% of those who discontinue medication relapse during pregnancy.

Fathers and Depression

• 10% of new fathers scored moderate to severe and Maternal depression increased risk.

Depressive Symptoms in Fathers

• Spike at 3-6 months postpartum and increased substance use/aggression with self isolation.

Assistance

• Lack of is due to gender bias and men underreport.

Single Parents

• Association of maternal depression with maltreatment risk and lack of childcare options
• Single fathers 3x more likely to use drugs/substances

LGBTQ+ Experiences

• Experiences under recorded and under researched
• Research centered in heterosexual relationships

Non-Gestational Parents

• May lack support and feel jealousy.

Many faces of perinatal mood/anxiety disorders:

• Differentiating between pregnancy and depression

Pregnancy vs Depression

• Mood/self esteem/sleep differs

Baby Blues: Non Disorder:

• Affects most new mothers, linked to hormone fluctuations and sleep deprivation. Lasts for 2 weeks after birth but if it persist then it isn't baby blues

DSM-V

• Diagnosis of peripartum specifier

Diagnostic Criteria for Major Depressive Disorder (MDD):

• 5 symptoms must be present with either that be depressed mood or loss of interest/pleasure:

9 Symptoms

• Depressed mood, diminished interest or pleasure, significant weight loss, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, worthlessness or guilt, diminished ability/indecisiveness, and recurrent thoughts of death/suicide

Specifier: Peripartum Onset

• The depressive episode occurs during pregnancy or 4 weeks postpartum.

Additional Features of Peripartum Onset Depression

• Includes anxiety and, in rare cases, psychotic features.
• It impacts development through impacting and influence on parenting, and key contributors are Risk factors.

Differential Diagnosis

• It is differentiated from disorders and from other, underlying health conditions

Treatment Options

• Consists of psychotherapy, particularly Cognitive Behavioral Therapy (CBT) or medication
• Lifestyle modifications improving social support and adequate sleep, or hospitalization

Generalized Anxiety Disorder

• (GAD): Excessive worry and anxiety about various events for at least 6 months.

DSM-5 criteria:

• Presence of excessive anxiety and uncontrollable worry

Associated Symptoms:

• With at least three or more in adults or one in children, including restlessness, fatigue, difficulty, irritability, muscle tension, and sleep disturbance

Clinical Distress or Impairment:

• Where anxiety causes impairment in important areas of functioning

Exclusion Criteria

• That the anxiety is not better explained by other mental disorders or a substance

Differential Diagnosis

• Distinguishing from things like, Panic, Social, and OCD disorder, or medical conditions

Treatment Options:

• Includes therapy, specifically CBT, medication, and lifestyle changes

Prevalance

• 15.8% prenatal and and 8-20% postpartum

Fathers

• Experience anxiety during prenatal/postnatal period

Panic Disorder

• Recurrent/unexpected panic attacks with concern over additional attacks.

Panic Attack Symptoms

• Includes jumpy heart, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, chills, numbness, derealization, fear of losing control, and fear of dying.

Exclusion Criteria:

• Not a substance and unrelated to other mental disorders.

Differential Diagnosis:

• Differentiated from specific phobia, social anxiety disorder, GAD, and medical conditions.

Treatment Options:

• With focuses being therapy such as Cognitive Behavioral Therapy and medications such as SSRIs

Greater Fears:

• Fear of dying, going crazy or losing control

Perinatal OCD:

• Includes reaccurant thoughts, repetitive behaviors, anxiety and compulsions with perinatal women is 1.5-2x greater risk.

Perinatal OCD:

• Commonly contains Intrusive, thoughts that creates guilt, shame, and hyper vigilance

Common Presentations of OCD

• Feat of deliberate harm, accidental contamination, ordering, religious and checking

Exposure and Response Prevention ERP

• ERP requires specialized training, therapists directories

Thoughts

• thoughts do not equal action: Providers must ask about scary/unusual thoughts, educate the individual that thoughts do not equal action- thoughts are just thought.

V. Psychosis

• Perinatal OCD the parent knows its unhealthy/extreme anxiety
• Perinatal psychosis the parent does not recognize the actions/thoughts are unhealthy, may seem to have lessanxiety when engaging in the thoughts/behaviors,

Perinatal PTSD

• Is the result of a traumatic event, includes flashbacks, memories, and physical symptoms

Subcategories of PTSD

• It is followed by intrusions, avoidance, negativity, and hyperarousal

Prevalence:

• Community samples show prevalence of both prenatal/postpartum PTSD

Birth Trauma

• Birthing person experiences trauma, can involve injury/death, intense fear

Potential traumatic events

• Includes c-section, NICU complications and failed response

Effects include-

• Powerless, lack of support

Creating trauma informed plan- Can help mom advocate

Potential Consequences of Perinatal PTSD

• Avoidance, bonding, sexual dysfunction, anxiety, future pregnancy

Maternal Mortality:

• Each year 50,000 suffer near fatal factors

Racial health disparities

• 2,000 deaths were due to pregnancy

Perinatal Biopolar disorder:

• diagnosed positive 2.6%

Bipolar 1 Symptoms:

• Elevated mood, decreased need for sleep
• Racing thoughts, increased energy

Bipolar 1 Disorder:

• Characterized by mania episodes and perinatal women most diagnosed 50% post partum. Can worsen while/after pregnant

Perinatal Psychosis

• Experience during post partum due to suicide or homicidal

Symptoms:

• agitation, poor concentration, and disorganized thoughts

Treatment:

• Requires maintaining meds and prioritizing sleep.

Actions

• Support, research, and education with long term risk including relapse.

Consequences of Paternal PMDAS:

• Hormonal shifts including:
• Increased estrogen and decrease testosterone/ increased cortisol/vasopressin

Most Pregnant Women:

• are already involved in healthcare
• has clear markers and is a defined period of risk

Postpartum

• Should be encouraged to get adequate rest, sleep, exercise, receive accurate PMAD information/tx/ postpartum plan

Sleep Hygeience:

• Warm bath pre bed, no electronics

Safety

• James McKenna, Kathleen Kendall tackett, Heler Ball, Acedemy of Breastfeeding Medicine, UNICEF

Periods and Traditions

• Cultural provides protection

Screening for Perinatal Mood and Anxiety Disorders

• Should be done because there are concerns/ unaware of screening tools
• Will reduce rates

Women of coloe defection:

• Are less likely screened and to attend follow ups

Standard of Care:

• American Academy and PSI recommends it

Edigburgh Postnatal Depression Scale (EPDS):

• Most validated tool (and postpartum), self administrations are accurate

Severeity

• Is determined by different scores based upon range.

Patinet Tool

• Is useful for general practitioners and has many languages available.

PDSS- postpartum despression screening scale

• Likert 35 item test with subscales

New Dads

• Systematic review of finding

Trauma

• trauma informed screening tools ACES.

Suicide

• More at risk/ideation
• Low has highest

Pregnancy Substance

• use among ages 15-44 and exposing developing baby to alcohol

Risk of still birth with

• Passive increased risk

Neonatal abstienence syndrome NAS

• Due to opioid during pregnancy

Feeding

• AAP infant should human milk exclusively first 6 months. Then foods and more breastfeeding while desired.

Breastfeeding

• bi directional and supports mental health less likely.

Dyphoric Milk Ejection Reflex (D-MER)

• The hormone is suppressed.

What does it support?

• Breastfeeding supports growth.

Medication and Support:

• is compatible while weighing untreated risks

Nonbinary:

• should see specialits on trans chestfed

Factors or PMADs

• Trauma

Loss of pregnancy:

• is caused for grieving, pain

Infertility:

• affects relationships and has many issues

Babies and PADs:

• Is post adoptive

Teen problems:

• are medical issues and PMAd risks

Factors for Military:

• Stressful. dual role

NICU PMADs:

• Witnessed as trauma

NICU

• Experience mental health

3 step of treatment.

• Tools: listening

The steps:

• Education, cultural, partnership