Mental Health and Womens Health Ellen Haller, M.D. Professor of - - PDF document

Mental Health and Women’s Health

Ellen Haller, M.D. Professor of Clinical Psychiatry UCSF Department of Psychiatry

UCSF Dept. of Psychiatry

Disclosure information

I have nothing to disclose.

UCSF Dept. of Psychiatry

Learning Objectives

• Know what to do when a pt c/o PMS/PMDD
• Review risks/benefits of antidep during preg
• Learn about post-partum mental health

UCSF Dept. of Psychiatry

UCSF Dept. of Psychiatry

Premenstrual Syndrome

Braverman 2007

• PMS described for centuries &

across cultures; term 1st used in 1950s

• Most women have some PMS

symptoms during some of their ~400 menstrual cycles

• More significant PMS symptoms in

~30%

UCSF Dept. of Psychiatry

Premenstrual Dysphoric Disorder (PMDD)

Cunningham J, 2009; Di Giulio, Reissing 2006

• 3-8%
• Starts in 20s; worsens over time
• PMDD dx criteria in syllabus

– Is now formal dx in DSM-5

• For up to 90%, PMDD not dx’d
• For ~40% of pts reporting PMDD, correct dx

= premenstrual exacerbation of other d/o

• Need to r/o other psych d/o and hypothy,

then prospectively track sxs

UCSF Dept. of Psychiatry Symptoms 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Days of period Symptoms 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Days of period Month _____________ Grade each symptom daily: None = 0 Mild = 1 Moderate = 2 Severe = 3 UCSF Dept. of Psychiatry Symptoms 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Irritable 2 2 3 3 3 3 2 1 Depressed 1 2 2 3 3 3 2 1 Fatigued 1 1 2 2 2 3 3 2 1 Days of period x x x x x Symptoms 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Irritable 1 Depressed 1 Fatigued 1 Days of period Month __April, 2013_____________ Grade each symptom daily: None = 0 Mild = 1 Moderate = 2 Severe = 3

UCSF Dept. of Psychiatry

Etiology

Di Giulio, Reissing 2006

• No abnormal levels of hormones
• No hormonal dysregulation
• Sensitivity to normal cyclical

hormonal changes

UCSF Dept. of Psychiatry

Which of the following interventions is proven to help reduce PMS symptoms?

1. Progesterone supplementation 2. The antidepressant, bupropion (Wellbutrin) 3. Calcium supplementation 4. Increasing salt intake

UCSF Dept. of Psychiatry

PMS/PMDD Treatment

Kroll, Rapkin, 2006

• Initial approach = basic wellness:

– Healthy diet – Stop smoking – Exercise – Adequate sleep – Stress management

UCSF Dept. of Psychiatry

PMS Treatment with Calcium

Thys-Jacobs et al, Am J OB Gyn 1998

• Multi-center, randomized, placebo

controlled study, N=497

• 600 mg bid x 3 cycles
• 55% had >50% improvement in global sxs

– 36% with placebo

• 48% reduction in total sxs scores

– 30% with placebo

• Calcium relieved both emotional &

physical sxs

• HOWEVER, recent study: SSRI better than

Ca or PBO for pts with PMDD (Yonkers, 2013)

UCSF Dept. of Psychiatry

PMDD Treatment with SSRIs

• Continuous dosing
• Luteal phase dosing
• AKA Intermittent dosing
• Help emotional & physical sxs
• In gen’l, respond to lower doses

& quicker

• Discontinuation sxs rare

UCSF Dept. of Psychiatry

Efficacy of SSRIs in PMS

Margoribanks J et al, Cochran Library, 2013

UCSF Dept. of Psychiatry

OCPs for PMDD

Joffe, Cohen, Harlow 2003

• Not helpful: Progesterone alone &

most combo OCPs

– May make sxs worse

• Helpful: Yaz

– Drospirenone 3 mg + ethinyl estradiol 20 mcg

UCSF Dept. of Psychiatry

Yaz for PMDD

Yonkers et al, 2005

• Multi-site, DB, RCT
• N=450, all with PMDD, 18-40 yo
• Daily ratings
• 24 days on & 4 days off (with inert pill)

UCSF Dept. of Psychiatry

Yaz for PMDD

Yonkers et al, 2005

• Found signif. diff betw groups
• Total sx score:

– 47% ↓ in active drug group over 3 tx cycles – 38% ↓ in PBO group

• Response (50% ↓ in scores)

– 48% of active drug group – 36% of PBO group

• Drop-outs: 15% vs 4%

– Most common SE = nausea & intermenstrual bleeding

UCSF Dept. of Psychiatry UCSF Dept. of Psychiatry

How common is depression in women?

Kessler, 2003

• 20-25% of all women will experience at

least 1 episode of depression in their lives

• Boys & girls have equal rates of

depression

• Beginning with puberty, rates ↑ for girls
• Overall, twice as common in women

UCSF Dept. of Psychiatry

“I feel miserable”

32 yo with 6 mo h/o depressed mood and:

• insomnia
• low energy
• poor concen.
• decr appetite
• less interest
• passive SI
• Fn at work impaired
• Sxs began after parents announced div.
• Had 1 prior episode depression

UCSF Dept. of Psychiatry

Treatment Plan for “I feel miserable”

• Course of Cognitive Behavioral

Therapy (CBT)

• Rx with an SSRI
• Depression significantly improved

UCSF Dept. of Psychiatry

One year later...

UCSF Dept. of Psychiatry

• Pregnancy NOT protective
• 10-20% of pregnant women dev MDD
• Risk factors for depression in preg:

– Prior h/o dep – Poor social support – Psychosocial stresses – Ambiv about pregnancy

UCSF Dept. of Psychiatry

Course of Depression in Pregnancy

Cohen et al, 2006

• N = 201
• All with > 4 prior MDD episodes but in full

remission

• Recurrence during pregnancy if stayed
• n meds = 26%
• Recurrence if d/c meds = 68%

– 50% in 1st trimester – 90% by end of 2nd trimester

UCSF Dept. of Psychiatry UCSF Dept. of Psychiatry

Treatment of Depression During Pregnancy

• Psychotherapy proven effective

– Interpersonal Psychotherapy (IPT) – Cognitive Behavioral Therapy (CBT)

• Antidep Rx--main areas of concern:

– Congenital organ malformations – Adverse effects in neonate – Impact on child’s development:

• Cognitive
• Behavioral

UCSF Dept. of Psychiatry

Which is the most true statement about antidepressants in pregnancy?

1. SSRIs are completely safe 2. TCAs are contraindicated 3. Not enough data exists to help make an educated recommendation 4. An individualized risk-benefit assessment must guide decision-making 5. SSRIs are contraindicated

UCSF Dept. of Psychiatry

TCAs During Pregnancy

Yonkers et al, 2009

UCSF Dept. of Psychiatry

SSRIs During Pregnancy

Bakker, 2012; Diav-Citrin & Ornoy, 2012; El Marroun et al, 2012

• No incr rate of congenital

malformations

• BUT, paroxetine may be different

– Cardiac malformations – Now Class D per FDA

• Level II UTZ at 16-20 wks

UCSF Dept. of Psychiatry

Perinatal Effects of SSRIs

Levinson-Castiel, 2006

• Neonatal adaptation syndrome--15-30%

exposed neonates

• Multiple sxs reported

– Agitation, jitteriness, sleep disturbance – Tremor – Rigidity – Feeding problems – Excessive crying

• Typically resolve w/in 48 hrs w/o medical

intervention

• Consider ↓ or d/c of antidep. prior to

delivery

UCSF Dept. of Psychiatry

SSRIs and PPHN

Hanley GE & Oberlander RF, 2013 and Wilson et al, 2011

• 1-2/1000 of all live births
• Manifests w/in 1st day of life
• Mortality rate ~10%
• SSRIs may incr risk 1.8-6X
• Recent study found key risk factor was C-

section before onset of labor (incr risk x5)

UCSF Dept. of Psychiatry

Other antidepressants during pregnancy

Cole et al, 2007; Yonkers et al, 2009

• Bupropion: no evidence of congenital

malformations

• Duloxetine, escitalopram,

mirtazapine, nefazodone, venlafaxine, and duloxetine – Fewer reports; no evidence of congenital malformations

UCSF Dept. of Psychiatry

Which statement is true?

Child development is adversely impacted by:

• 1. In utero exposure to SSRIs
• 2. Mother’s ability to successfully practice

mindfulness

• 3. Level of severity of mother’s depression
• 4. Presence of depression in the father
• 5. In utero exposure to heavy metal music

UCSF Dept. of Psychiatry

Child Development After Fetal Exposure Nulman et al, 2012

• Prospective study of kids of depressed

women

• 1. Venlafaxine (n=62)
• 2. SSRIs (n=62)
• 3. Untreated depression (n=54)
• 4. Non-depressed Controls on no meds (n=62)
• Intelligence and behav outcomes measured

when 3-6 yo

• Grps 1, 2 & 3 had lower IQs and incr behav

problems than grp 4

• Severity of maternal dep in preg & at

testing is what predicted child behav

UCSF Dept. of Psychiatry

What about risk of autism?

Rai et al 2013

• ASD affect ~1-2%
• Dysfunctional serotonin signaling may play

role in pathogenesis

• Swedish study; antidep during preg.

– 1,679 ASD – 16,845 controls with data on antidep use

UCSF Dept. of Psychiatry

What about risk of autism?

Rai et al 2013

• Incr risk for ASD if took antidep compared

to women with dep who did not – Antidep use explained 0.6% of the cases of ASD

• Assoc found; not clear if causation
• Hard to determine impact of depression

itself

– Severity not quantified – More ill pts more likely to be on meds

• Unclear if other exposures e.g. Drugs,

Etoh...

UCSF Dept. of Psychiatry

Deciding to Rx Antidep in Pregnancy

Yonkers et al, 2009; El Marroun et al, 2012; Diav-Citrin & Ornoy, 2012

• Need to perform individual

risk:benefit analysis

• Assess severity of anxiety/

depression & h/o response to treatment

• Document other exposures

– alcohol, cigs, Rx & OTC drugs

• Document informed consent

UCSF Dept. of Psychiatry

Post-partum mental health

UCSF Dept. of Psychiatry

“I just feel so tired”

• 37 yo primip
• No prior h/o depression
• Now 7 wks postpartum
• Sxs:

– depressed mood – fatigue – overwhelmed and ashamed – anxious about caring for baby; fears mistake – ↓ appetite – insomnia--even when baby asleep

UCSF Dept. of Psychiatry

Differential Diagnosis

• Persistent Depressive D/O

– AKA Dysthymia

• Bipolar d/o
• Substance abuse/dependence
• Sleep deficit
• Medical conditions

– Anemia – Thyroid dysfunction

• Intimate partner abuse
• Post-partum depression (PPD)

UCSF Dept. of Psychiatry

Post-partum depression occurs after what percent of live births?

• 1. 0-5%
• 2. 6-10%
• 3. 11-15%
• 4. 16-20%
• 5. 21-25%

UCSF Dept. of Psychiatry

Cohen LS. Depress Anxiety. 1998:1:18-26.

Transient, nonpathologic Medical emergency Serious, disabling Postpartum Depression

10-15% 2/3 have onset by 6 wks postpartum

Postpartum Blues

50% to 70% ↑ risk for MDD

Postpartum Psychosis

0.01%

70% are affective (bipolar, MDD)

Spectrum of Postpartum Mood Changes

UCSF Dept. of Psychiatry

PPD Risk Factors

Bloch et al, 2005

• Psychosocial stress
• h/o depression
• h/o PMDD
• Prior h/o PPD (50% risk)
• Depression during current pregnancy

UCSF Dept. of Psychiatry

Therefore,

UCSF Dept. of Psychiatry

Edinburgh Postnatal Dep Scale

Cox, 1987

• 10 item questionnaire
• Score of >12 indicates probable PPD
• In public domain; it’s been included in

your syllabus

UCSF Dept. of Psychiatry

PPD Management Recommendations

Yonkers et al, 2011; Carter et al, 2010; Apter et al, 2011; Studd & Nappi, 2012

• Reassurance & support
• Postpartum Support International

– www.postpartum.net

• Psychotherapy

– Interpersonal Psychotherapy (IPT) – Cognitive Behavioral Therapy (CBT)

• Medications

UCSF Dept. of Psychiatry

Pharmacotherapy for PPD

Yonkers et al, 2011; Apter et al, 2011; Studd & Nappi, 2012

• Relatively few studies have evaluated

antidep specifically for PPD

• No study compares psychotx &

pharmacotx

• BOTTOM LINE: Assume Rx for PPD has

same response as in other depression

UCSF Dept. of Psychiatry

Psychotropic Drugs During Lactation

Davanzo et al, 2011; Sharma & Sharma, 2012

• All are excreted in human breast milk
• As a class, have more data in breast-

feeding than any other

• Sertraline, paroxetine, NTP & IMI are

most evidence-based meds

• Great resource: Lactmed (NIH)

UCSF Dept. of Psychiatry

Summary

• PMS/PMDD are real d/o

– Prospective charting useful tool – Mgmt = basic wellness → calcium → SSRIs intermittently or Yaz → SSRIs continuously

• Depression is more common in

women

• For pregnant pts, complete an

individualized risk-benefit analysis

• 3 classes of postpartum mood

disorders

UCSF Dept. of Psychiatry

Resources

Office of Women’s Health www.4woman.gov/owh/ American Psychiatric Association patient info www.healthyminds.org Center for Women’s Mental Health at Mass Gen’l www.womensmentalhealth.org Info on meds in breastfeeding (Lactmed) http://toxnet.nlm.nih.gov