Home Treatment of Depression

Destroy Depression

Destroy Depression is written by James Gordon, a former sufferer of depression from the United Kingdom who was unhappy with the treatment he was being given by medical personnell to fight his illness. Apparently, he stopped All of his medication one day and began to search for answers on how to cure himself of depression in a 100% natural way. He spent every waking hour researching all he could on the subject, making notes and changing things along the way until he had totally cured his depression. Three years later, he put all of his findings into an eBook and the Destroy Depression System was born. The Destroy Depression System is a comprehensive system that will guide you to overcome your depression and to prevent it from injuring you mentally and physically. Read more here...

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22 Tools Used to Detect the Presence of Depressive Symptoms in Pregnancy

These lay-administered tools facilitate data collection from a variety of patient groups. Furthermore, they reveal the presence of depressive symptoms without the need for time-consuming, costly analyses by mental health professionals. Specific details regarding four of the most commonly used self-report inventories are outlined here. The Beck Depression Inventory (BDI), first introduced in 1961, was revised and re-released in 1978 as a brief 10-min, self-administered questionnaire capable of detecting the presence of depressive symptoms in both female and male psychiatric patients. The BDI consists of 21 questions regarding various aspects of mood, including but not limited to sadness, suicidal ideation, loss of weight, and social withdrawal (14,14a). The BDI has been validated for use in pregnant women via comparison against the National Institute of Mental Health Diagnostic Interview Schedule III (15). It should be noted, however, that responses...

2111 Tricyclic and tetracyclic antidepressants

Tricyclic antidepressants (TCAs) inhibit ihe reuptake of the neurotransmitters, noradrenaline and serotonin, in the adrenergic neurones, which results in increased concentrations of those neurotransmitters at the receptor. Maternal exposure to antidepressants may be associated with a risk for spontaneous abortions. However, the underlying depression could also be a contributing factor (Hemels 2005). Kall n (2004) reports an increased risk for preterm birth and low birth weight.

2114 Other antidepressants

The antidepressants amineptine, amoxapine, atomoxetine, bupropion, duloxetine, iprindole, medifoxamine, mianserin, mirtazapine, nefazodone, oxitriptan, reboxetine, tianeptine, trazodone, venlafax ine, and viloxazine are not structurally related to TCAs, SSRIs or MAOIs. an increased incidence of congenital malformations or a consistent pattern of defects, although a higher than expected rate of cardiac anomalies had been discussed. Chun-Fai-Chan and colleagues also did not find an increased incidence of congenital malformations or other adverse prcgnancy outcomes after intrauterine first-trimester exposure among 136 pregnancies (Chun-Fai-Chan 2005). They found higher rates of spontaneous abortions, but these were similar to those in other studies examining the safety of antidepressants during pregnancy. Nefazodone and trazodone are related phenylpiperazine antidepressants which inhibit the reuptake of noradrenaline and serotonin and block the serotonin receptors in the synapses. There...

Depressive Symptoms During Pregnancy

Regardless of illness history, the emergence of depressive symptoms during pregnancy significantly increases the likelihood of PPD, and depression during pregnancy remains one of the most robust predictors of postpartum illness (Beck 2001 O'Hara 1986 O'Hara et al. 1984). One study demonstrated that women who were depressed at 18 weeks of gestation had a threefold greater risk of PPD than women who were euthymic during pregnancy (Heron et al. 2004). For women who were depressed at 32 weeks, the risk was sixfold higher. This study also demonstrated that anxiety during pregnancy significantly increases the risk of PPD.

491 Antidepressants in general

Under such circumstances, psychotherapeutic and (if necessary) psychopharmacological therapy should be considered. Apart from tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRI) are predominantly used. Among tricyclics, tertiary amines with pronounced anticholinergic and sedating characteristics (amitriptylin, imipramine, clomipramin, doxepin) are distinguished from secondary (desipramin, nnrtriptylin) and primary (amoxapin) amines, where these properties are less strong. Recently, 95 women with postpartum depression were treated with cither tricyclic nortriptyline or the SSRI sertraline. The proportions of women who responded and remitted did not differ between the drugs at 4, 8 or 24 weeks. The total side-effect burden of each drug was similar, although side-effect profiles differed between agents. Breastfed infant serum levels were near or below the level of quantifiability for both agents (Wisner 2006). In so far as they have been studied, the M P ratios of...

494 Other antidepressants

Due to the quantity and the results of documented experience, St. John's wort or hypericin preparations and mirtazapine are acceptable during breastfeeding. If compellingly indicated, moclobemid, venlafaxine, and bupropion are also tolerable. Whenever possible, the drugs of choice among tricyclic antidepressants or SSRIs are preferable. In general, monotherapy should be the goal. In cases of symptoms potentially associated with the drug therapy, a pediatrician and a teratology information center should be contacted to decide individually upon measuring drug values in the infant's serum, supplementary formula feeding, weaning, and or changing the therapy. As with all psychoactive drugs, there is insufficient experience on the long-term effects on breastfed children of ongoing maternal therapy.

1915antidepressants and breastfeeding

The clinicians of breastfeeding women diagnosed with postpartum depression must consider the different treatment options for their patients including antidepressants, hormonal therapy, or psychotherapy. In situations where the postpartum depression requires antidepressants, the safety of the nursing infant must be considered. Antidepressants taken during breastfeeding can induce adverse symptoms in the infant. The antidepressants that have been particularly problematic are nefazodone 102 , citalo-pram 103 , doxepin 104, 105 , and fluoxetine 106, 107 . Given the negative infant outcomes associated with maternal antidepressant therapies, the US Food and Drug Administration (FDA) has not approved any antidepressant for use during lactation 49 . Alternatively, depression during the postpartum period can impair maternal-infant interactions 108 , which in turn negatively affect infant cognitive development 109 , emotional development 109 , anxiety, and self-esteem 110 . In some cases, the...

Antidepressants in Breast Feeding The Data

As a class, antidepressants have been the focus of more published data on breast-feeding than any other class of medications. This database (summarized in Table 5-1) includes 687 separate measures of breast milk concentrations with more than 400 nursing infant serum measures. The majority of the reports, and of the infant serum measures, involve selective serotonin reuptake inhibitors (SSRIs). There have been numerous attempts to compare the extent of infant exposure and the relative safety of individual antidepressants. A novel approach taken by one group has been the measurement of infant blood serotonin before and during maternal treatment (Epperson et al. 2001, 2003). Although sample sizes are limited, Other antidepressants Other antidepressants (continued) Note. AAP American Academy of Pediatrics N A not mentioned by name or category ODV O-desmethylvenlafaxine PDR Physicians' Desk Reference SSRI selective serotonin reuptake inhibitor TCA tricyclic antidepressant. +Classified by...

Antidepressants in Breast Feeding Infant Monitoring

Routine breast milk and or nursing infant serum sampling is not indicated by the current literature. The accuracy of such measures outside of a research laboratory would be suspect, and the antidepressants are not associated with alterations in other laboratory indices with limited exceptions such as the syndrome of inappropriate antidiuretic hormone. It is important to note that data on the placental passage of antidepressants (Hendrick et al. 2003b Z.N. Stowe, unpublished data) have demonstrated umbilical cord concentrations at delivery ranging from 40 to over 100 of maternal serum concentrations. By comparison, a nursing infant would have to breast-feed exclusively for more than 2 years to accrue the level of antidepressant exposure that occurs during a single month of pregnancy. Furthermore, newborn infants have a full complement of metabolic enzymes and a1-glycoprotein concentrations, comparable to those of adults. Therefore, concern about antidepressant exposure via breast milk,...

492 Tri and tetracyclic antidepressants

Breastfeeding women taking 75-175 mg amitriptyline a day were studied (survey in Weissman 2004). The M P ratio was 1 the relative dosage for a fully breastfed baby, including the active metabolites, should not, in light of current experience, exceed 2.5 . Amitriptyline and nortriptyline could not be dctccted in the infants' serum. The children had no acute clinical symptoms. Among the 10 infants breastfed while their mothers were taking tricyclic antidepressants, development in the first year of life did not differ from that of the artificially fed infants in a control group (Yoshida 1997A). Recommendation. When drug treatment for depression is urgently needed, monotherapy with amitriptyline, clomipramine, nortriptyline, imipramine, desipramine or dosulepine is the treatment of choice during breastfeeding. With compelling indications, other tricyclics are also acceptable. Doxepin should be avoided. In cases of symptoms potentially associated with drug therapy, a pediatrician and a...

84 Antidepressants

Some investigators recommend treatment with antidepressants in conjunction with a mood stabilizer after delivery to reduce the risk of developing PPD in women with recurrent depressive disorder (5,7,110). Postpartum prophylaxis with an antidepressant agent immediately after delivery has been noted to reduce depression rates dramatically in women with recurrent depression, with a 6.2 rate in women receiving the medication vs 62 in women not on prophylaxis treatment. It is not known whether this finding also applies to women with bipolar disorder (7,110). The use of antidepressants in lactation is reviewed in Chapter 3, thus it is not reviewed here. Antidepressants may precipitate mania or rapid cycling in women who suffer from PPD or postpartum psychosis with prominent depressive features (112,117,167). If an antidepressant is used in managing postpartum psychosis, it should, of course, be used only in conjunction with a mood stabilizer (168,169). Further details on the use of...

Considering nutritional supplements

Many women choose to treat common ailments with over-the-counter plant extracts or other natural medications. Some are considered completely safe during pregnancy, but keep in mind that, because they are considered nutritional supplements, these agents are not regulated by the FDA. Despite the fact that many pregnant women use these supplements, very few studies have evaluated their safety or shown that they actually give a benefit during pregnancy. Many of these pills are also unregulated for dose, so one pill may contain twice as much as the next. Some of these supplements are combinations of different herbs or extracts and the interactions are unknown and unstudied. St John's wort, for instance, is an herb commonly used to treat depression, sleep disorders, and viral infections. Not only can this herb interact with other medications, but also, its safety benefit during pregnancy has not been studied, so use it with caution.

51 Nonpharmacological Treatment Options

Two major studies involving the use of IPT for pregnant, depressed women were undertaken by the same investigator (74,75). Both investigations found IPT to be an effective therapy for antepartum depression (74,75). It should be noted, however, that no investigations have compared IPT to antidepressant treatment. Although data on the efficacy of IPT for prenatal depression are not as extensive as those for antidepressants, it is a reasonable treatment option for patients who wish to avoid the use of medications or who experience antidepressant-refractory illness.

52 Pharmacological Treatment Options

Tricyclic Antidepressants and Safety in Pregnancy Imipramine, the first of the tricyclic antidepressants (TCAs), was introduced in 1958 (80). Since then, more than 10 other TCAs have been designed, produced, and marketed. These agents achieve their anti-depressant effects principally via inhibition of central norepinephrine reuptake and, to a lesser extent, serotonin reuptake (80). Although TCAs have been widely prescribed, their use has declined over the past 20 yr, likely due to the advent of medications with fewer adverse effects. In the early 1970s, a case report of a child born with bilateral amelia following in utero TCA exposure (81) caused widespread fear that TCAs were teratogenic. Since then, 3 prospective and more than 10 retrospective studies have become available regarding the safety of TCA use in the first trimester of pregnancy (82-88). The individual and pooled results ofthese studies suggest that TCA use in pregnancy is not associated with an increase in the...

3 Effect Of Pregnancy On Drug Metabolism

Wide interindividual variations exist in the degree ofmedication clearance present during pregnancy (18). For medications that must remain within a specific therapeutic window (e.g., lithium, tricyclic antidepressants, antiepileptic drugs), it is advisable to increase the monitoring frequency ofblood levels ofmedications. Although the optimal frequency Antidepressants

Fetal Risk Summary

Neonatal withdrawal after in utero exposure to other antidepressants (see Imipramine), but not with amitriptyline, has been reported. However, the potential for this complication exists because of the close similarity among these compounds. Urinary retention in the neonate has been associated with maternal use of nortriptyline, an amitriptyline metabolite (see Nortriptyline) (17). In summary, although occasional reports have associated the therapeutic use of amitriptyline with congenital malformations, the bulk of the evidence indicates these widely used drugs are relatively safe during pregnancy. The single case of gross overdose is suggestive of an association between amitriptyline, perphenazine, or both, and malformations, but without confirming evidence no conclusions can be determined. Because of the experience with tricyclic antidepressants, one review recommended they were preferred during gestation over other antidepressants (2).

13 The Differential Diagnosis

1 Symptom included in the DSM-IV criteria for major depressive disorders. dysphoric mood, tearfulness, irritability, emotional lability, anxiety, and sleep disturbance, peaks around 3-4 d postpartum and resolves within hours to a few days. Although the baby blues are self-limited in duration, the more severe the symptoms during this time period, the more likely the woman is to meet criteria for major depressive disorder (MDD) at

Prevalence of Mood and Anxiety Disorders During Pregnancy

Although some reports describe pregnancy as a time of affective well-being during which protection against psychiatric disorders is conferred, at least one prospective study describes equal rates of minor and major depression (approximating 10 ) among gravid and nongravid women (O'Hara et al. 1990). Several other studies also note high rates (up to 20 ) of clinically significant depressive symptoms during pregnancy (Evans et al. 2001 Gotlib et al. 1989 Marcus et al. 2003 O'Hara 1986, 1995). A personal history of affective illness significantly increases this risk (Gotlib et al. 1989 O'Hara 1995), and the risk appears to be particularly high among women with recurrent depression who discontinue maintenance treatment proximate to conception. A recent prospective study indicated that 75 of women who discontinue medication experience recurrent illness during pregnancy (Cohen et al. 2004a) in most cases, relapse occurred during the first trimester. Other risk factors for antenatal...

Neill Epperson and Jennifer Ballew

Postpartum depression (PPD) or, simply, postpartum are the most commonly used lay terms for describing major depressive disorder occurring in the postnatal period. Whether the disorder occurs de novo, is a relapse of a previous depressive episode, or has its origin in the antepartum period, depression after childbirth is associated with significant maternal and infant morbidity and, in worst cases, mortality. With most epidemiological studies demonstrating a prevalence of 10-13 , PPD is one of the most common complications of childbirth (1,2). Yet, the pathogenesis, natural history, and treatment of the disorder have been shrouded in mystery and myth as society and science has imbued motherhood with a cloak of sanctity that cuts both ways. Attempts to protect mothers and their offspring from unnecessary intrusions or potential harm have unwittingly limited detection of PPD in the clinical setting and the investigation of its pathogenesis and treatment in the scientific arena.

2 Biological Underpinnings Of Postpartum Mood Disorders

PPD emphasize the importance of the individual's sensitivity to pregnancy-related hormonal changes (44,45). By focusing on women who have demonstrated vulnerability to mood changes during the puerpe-rium by having experienced PPD with a previous pregnancy, Bloch and colleagues overcame several of the shortcomings of previous studies. Women were studied outside of the postpartum period when manipulation of hormone levels would not interfere with breast-feeding nor exacerbate PPD at a time when recovery is crucial for both the mother and child. Administration of supraphysiological levels of estrogen and progesterone to mimic a pregnancy allowed the investigators to compare mood responses in those at high risk of depressive symptoms (history of PPD group) with those who are at low risk (no history of PPD), while at the same time controlling the hormonal milieu in each subject such that serum estradiol and progesterone levels were not significantly different between groups. Those women...

Treatment of Mood Disorders During Pregnancy

With the advent of newer and better-tolerated antidepressants, as well as enhanced public awareness of available pharmacother-apy for depression, a growing number of women are prescribed antidepressant medications during the childbearing years. For women with recurrent major depression who are receiving maintenance antidepressant treatment and who plan to conceive, the clinician and patient must decide whether to maintain or to discontinue antidepressant treatment during pregnancy. Ideally, decisions regarding the use of psychotropic medications during pregnancy should be made prior to conception. Prior to pregnancy, the clinician must provide information regarding the patient's risk of relapse in the setting of medication discontinuation. The clinician must also take into account the risk of chronic, recurrent depression and its attendant morbidity in patients who experience depressive relapse after medication discontinuation (Keller et al. 1983 Mueller et al. 1999 Post 1992). be...

Treatment of Anxiety Disorders During Pregnancy

For patients with severe anxiety disorder, maintenance medication may be a clinical necessity. For those with OCD, SSRIs or clomipramine is the first line of treatment. Because of the concerns regarding serious withdrawal symptoms in infants exposed to clomipramine in utero, the SSRIs are preferred. However, clomipramine may be used with close monitoring in those women who do not respond to or are unable to tolerate SSRIs. Use of the SSRIs or TCAs is a reasonable option for the management of panic disorder and GAD during pregnancy (Altshuler et al. 1996). If patients do not respond to these antidepressants, benzodiazepines may be considered (Weinstock et al. 2001).

2112 Selective serotonin reuptake inhibitors SSRIs

SSRIs are equally effective but are better tolerated by some patients than TCAs. The SSRIs are also safer than other antidepressants for the mother and fetus in women with suicidal ideation. Fluoxetine is a long-acting SSRI. The half-lives of fluoxetine and the metabolite nor-fluoxetine are several days and 14 days, respectively. The half-life of citalopram is 36 hours fluvoxamine, paroxetine, and sertraline have half-lives of less than 24 hours. Maternal exposure to antidepressants may be associated with a risk for spontaneous abortion. However, the underlying depression could also be a contributing factor (Hemels 2005). Several investigators have found an increased incidence of preterm birth when SSRIs have been used throughout pregnancy or in the last half of pregnancy (Kallen 2004. Costei 2002, Simon 2002, Ericsson 1999, Chambers 1996, Goldstein 1995). Here, too, the underlying depression could be a contributing factor. In most studies, there was no control for the impact of...

11 Treatment Guidelines

No consensus exists regarding the most suitable time to reintroduce prophylaxis (117,119). The most prudent plan is to use medication(s) to which the individual woman has previously responded well and to prepare a plan for rapid augmentation if breakthrough episodes of hypoma-nia or depression or mixed eipsodes occur during the immediate postpartum period (115). It is well known that women with bipolar disorder who discontinue lithium prior to pregnancy and have remained well during the pregnancy are at significantly increased risk of relapse, which may take the form of manic psychosis or a major depressive episode, within the first month postpartum (174). Although some authors suggest reinstituting mood stabilizers in the second or third trimester of pregnancy when the teratogenic risk is lower, many patients may prefer to defer prophylaxis until immediately after delivery (117). Particularly vulnerable women may require treatment throughout their pregnancies. Women who are...

Treatment Planning for the Patient With Bipolar Disorder in the Postpartum Period

Use of an anticonvulsant or an antipsychotic agent for protection during early postpartum months can also be considered, particularly if lithium treatment has been unsuccessful or poorly tolerated in the past. These options are considered secondary choices, however, since there is no research on their use to prevent postpartum illness in women with BD. Use of antidepressants during pregnancy is also widely considered to be generally safe, although their use without a mood-stabilizing treatment in BD is not recommended.

Breast Feeding Summary

Bupropion is excreted into human breast milk. A 37-year-old lactating woman was treated with the drug, 100 mg, three times daily (4). She was nursing her 14-month-old infant twice daily at times corresponding to 9.5 and 7.5 hours after a dose. Peak milk concentrations of bupropion occurred 2 hours after a 100-mg dose with a value of 0.189 pg mL, but the peak plasma level measured, 0.072 pg mL, occurred at 1 hour. The milk plasma ratios at 0, 1, 2, 4, and 6 hours after a dose were 7.37, 2.49, 4.31, 8.72, and 6.24, respectively. Two metabolites, hydroxybupropion and threohydrobupropion, were also measured with peak concentrations of both occurring at 2 hours in milk and plasma. The ranges of milk levels and milk plasma ratios for the metabolites were 0.093-0.132 pg mL and 0.366-0.443 pg mL, respectively, and 0.09-0.11 and 1.23-1.57, respectively. The levels of a third metabolite, erythrohydrobupropion, were too low to be measured in breast milk (test sensitivity 0.02 pg mL). No adverse...

Pharmacological Treatment

Psychotropic agents can modify the symtoms of IBS by their action in modulating psychosocial factors, e.g. antidepressant medications (tricyclic antidepressants) in women who have major depression as co-morbidity with IBS. They can also modify the pain threshold in these patients. The choice of antidepressants will depend on the main presenting complaints and side-effect profiles for the individual patient. Tricyclic antidepressants are likely to be more effective in cases of diarrhoea and abdominal pain, due to its anticholinergic activity. A sedating tricyclic anti-depressant may be useful when there are associated sleep problems, whereas selective serotonin re-uptake inhibitors (SSRI) such as fluoxetine may help in cases that have constipation or bloating7.

Will Induction of Labor be Necessary

Some women will find it very difficult to come to terms with the fact that they are still carrying a fetus that is no longer alive in their womb. Studies have shown that a woman is much more likely to suffer from depressive symptoms after delayed delivery of a stillborn of more than three days. Most women will opt for an induction of labor to avoid this. The doctor may take into account the mental state, physical conditions and advise on when is the best time to induce delivery. The aim ultimately is to allow for a vaginal delivery. This avoids having to put the mum through the risks associated with a cesarean section.

Postpartum Depression

During the postpartum period, 10 -15 of women will present with more significant depressive symptoms, or PPD (P. J. Cooper et al. 1988 Cox et al. 1993 Kumar and Robson 1984 O'Hara et al. 1984). In contrast to postpartum blues, PPD is more pervasive and may significantly interfere with a mother's ability to function and to care for her child. Depression most commonly develops insidiously during the first 1-3 postpartum months, although some women report the acute onset of symptoms shortly after childbirth (P.J. Cooper et al. 1988). A significant subpopulation of women actually experience the onset of depressive symptoms during pregnancy (Josefsson et al. 2001). Clinically, PPD is indistinguishable from other types of non-psychotic major depression. Women typically present with depressed mood, tearfulness, irritability, and loss of interest in their usual activities. Insomnia, fatigue, and loss of appetite are frequently described. Women often express ambivalent or negative feelings...

Psychosocial Variables

Psychosocial variables appear to play an important role in determining vulnerability to affective illness during the postpartum period. One of the most consistent findings is that among women who report marital dissatisfaction and or inadequate social supports, postpartum depressive illness is more common (Beck 2001 O'Hara 1986 Paykel et al. 1980 Robertson et al. 2004). Several investigators have also demonstrated that stressful life events occurring either during pregnancy or near the time of delivery appear to increase the likelihood of PPD (Beck 2001 O'Hara 1986 Paykel et al. 1980 Robertson et al. 2004).

History of Affective Disorders

There is a well-defined association between all types of postpar-tum psychiatric illness and a personal history of affective disorder. At highest risk are women with a history of postpartum psychosis it is estimated that up to 70 of women who have had one episode of puerperal psychosis will experience another episode following a subsequent pregnancy (Davidson and Robertson 1985 Garfield et al. 2004 Kendell et al. 1987). Similarly, women with histories of PPD are at significant risk, with rates of postpartum recurrence as high as 50 (Garfield et al. 2004). Women with bipolar disorder also appear to be particularly vulnerable during the postpartum period, with rates of postpartum relapse ranging from 30 to 50 (Nonacs et al. 1999 Reich and Winokur 1970 Viguera et al. 2000). This population is also at increased risk of postpartum psychosis (Reich and Winokur 1970). The extent to which a history of unipolar depression influences risk for postpartum illness is less clear. Although studies...

Impact of Reproductive Hormones on Risk of Illness

Tories of PPD and a control group of women with no history of affective illness. Both groups were given a gonadotropin-releasing hormone agonist, leuprolide acetate, to shut down ovarian function. Then the women were treated with supraphysiologic levels of estrogen and progesterone for a period of 8 weeks to mimic the hormonal changes that take place during pregnancy. The hormones were abruptly withdrawn in order to simulate the postpartum period. During the withdrawal phase, five of the eight women with histories of PPD developed significant depressive symptoms, similar to those they had experienced during prior episodes of PPD. In contrast, none of the eight women with no history of mood disorder developed mood symptoms during the hormone withdrawal phase. These data suggest that at least some women who develop PPD may be differentially sensitive to changes in the hormonal environment and, when exposed to these changes after delivery, may develop clinically significant depressive...

Hormonal Interventions

These studies suggest a role for estrogen in the treatment of women with postpartum psychiatric illness however, these treatments remain experimental. Estrogen delivered in the acute post-partum period is not without risk and has been associated with changes in breast milk production, as well as more significant, thromboembolic events. Because antidepressants are safe, well tolerated, and highly effective, they remain the first choice for treatment in women with PPD.

Prophylactic Interventions

Treatment with either a TCA or an SSRI, administered after delivery, resulted in a reduction in risk of postpartum illness (Wisner and Wheeler 1994). In a subsequent double-blind, placebo-controlled study from the same group, 22 women with histories of postpartum depression were randomly assigned to receive treatment with either sertraline or placebo (Wisner et al. 2004b). Ser-traline was introduced on the first postpartum day (on average, within 15 hours of delivery) at a dose of 50 mg per day and increased to 75 mg at week 5. Of the 14 women who received ser-traline, only 1 woman had recurrence of depression. In contrast, 4 (50 ) of the 8 women in the placebo group developed depressive symptoms. Other studies have not yielded positive results. A randomized, placebo-controlled study from the same group did not demonstrate a positive effect in women treated prophy-lactically with nortriptyline (Wisner et al. 2001). The authors hypothesized that nortriptyline may be less effective than...

192prevalenceincidence

The Agency for Healthcare Research and Quality (AHRQ) recently conducted a systematic review of studies on the prevalence and incidence of postpartum depression during the first 12 months after delivery 5 . During the postpartum period, the point prevalence of major and minor depressive episodes starts rising and is at its highest in the third month at 12.9 . During the fourth month through the seventh month postpartum, the prevalence decreases slightly to between 9.9 and 10.6 . 5 . When looking at the point prevalence for major depression alone, major depressive episodes peak at 2 months (5.7 ) and 6 months (5.6 ) after delivery. Regarding period prevalence, the AHRQ report revealed that after delivery up to 19.2 of mothers have either major or minor depressive episodes during the first 3 months, with 7.1 having a major depressive episode. Incidence of a new episode of major or minor depression during the period of the first 3 months postpartum can be up to 14.5 of mothers, with 6.5...

171 Antenatal Psychiatric Disorders 209

Persistent anxiety and depressive symptoms affect the woman's general health and satisfaction with pregnancy. The increased production of maternal and fetal cortisol in these patients may also be associated with increased uterine artery resistance which may result in11,12

195cultural perspectives of postpartum depression

Horowitz and colleagues 22 conducted focus groups with mothers between 2 and 4 months after delivery in nine different countries the United States, Australia, Finland, Guyana, India, Italy, Korea, Sweden, and Taiwan. How mothers described their postpartum depressive symptoms was remarkably similar across these countries. Common cognitive symptoms reported included poor concentration, worry, and indecisiveness. The most frequently cited emotional symptoms were anger, irritability, depression, sadness, guilt, anxiety, loneliness, fear, inadequacy, and tearfulness.

Preconception Issues And Care

Women with a past history of severe depression or puerperal psychosis should be counselled regarding relapse rates (about 50 ) in future pregnancies. Medication should not be abruptly discontinued. Many antidepressants are safe in pregnancy mood stabilisers may cause fetal defects, but again the risk-benefit ratio should be assessed to decide whether discontinuation is indicated.

19124The Role of DHA in Neurotransmission

Otto and colleagues 73 investigated plasma phospholipid DHA in 112 women at delivery and at 32 weeks postpartum. The EPDS was given to the women at the 32-week time point to assess postpartum depression. There was an inverse relationship between DHA status and depressive symptoms. In a study of 865 Japanese women Miyake and colleagues 75 investigated risk of postpartum depression related to dietary fatty acid intake. Again, the EPDS was used to evaluate postpartum depression and diet history questionnaires were self-administered to measure dietary fatty acid intake. There were no significant relationships between dietary fish consumption or n-3 fatty acid intake and postpartum depression. Likewise, Browne et al. 76 investigated maternal fish consumption and plasma DHA status after birth in relation to postpartum depression diagnosed using the Composite International Diagnostic Interview. There were no associations between maternal fish consumption during pregnancy or maternal DHA...

19135 Pyridoxine Vitamin B6

Few investigations have been conducted investigating the role of B6 in depression however, an inverse association between plasma B6 levels and depressive symptoms has been reported 91 . With respect to postpartum depression, only one investigation has included the assessment of the association with B6 and reported no measurable association with postpartum depression 88 . Further work is necessary to determine if a definitive relationship exists between B6 status and postpartum depression.

Pharmacologic Treatment Options for Unipolar Depression and Bipolar Disorder in Breast Feeding

A MEDLINE search identified 148 original research reports for the use of antidepressants or mood stabilizers during breastfeeding. With few exceptions, the parent compound and or metabolites were found in human breast milk thus, the nursing infant is always exposed to medication. To afford a detailed characterization of infant exposure and provide a basis for comparing individual medications, investigators have typically emphasized either breast milk concentration or the nursing infant's serum concentration.

1916effect of postpartum depression on breastfeeding success

Given the benefits of breastfeeding for both mother and infant, breastfeeding mothers with postpartum depression may benefit from this choice of feeding. However, the additional demands of breastfeeding could also be overwhelming for women experiencing postpartum depression, and care should be taken to support mothers deciding to formula feed. Those women who decide to breastfeed will likely need additional support to foster the continuation of breastfeeding during this difficult time. Although breastfeeding may reduce depressive symptoms during the postpartum period, mothers with depressive symptoms are more likely to discontinue breastfeeding 111-115 . Referrals to area lactation consultants and breastfeeding support groups such as La Leche League can be extremely helpful to mothers with PPD who are interested in continuing breastfeeding.

21 Parent Factors Impacting Child Outcomes

Major depression 10 her lifetime (14). Environmental context is also important in the etiology of psychiatric disorders, and the expression of a child's genetic liability appears to be impacted by and interact with the environmental context (15,16). The stress-vulnerability model, for instance, proposes that vulnerability, determined by a combination ofgenetic and early environmental events, interacts with later environmental stress to either precipitate the onset of a psychiatric disorder or to trigger a relapse of illness symptoms. For example, loss of an important relationship in a vulnerable child can constitute a stress that may precipitate or exacerbate a major depressive episode. Genetic, twin, and family studies indicate that children born to parents with major mental illnesses are at higher risk to develop the same and other psychiatric illnesses than children whose parents do not have the illness. Table 1 shows the risks for children of parents with schizophrenia, major...

Mood Stabilizers in Breast Feeding Infant Monitoring

In contrast to antidepressants, mood stabilizers might directly affect laboratory indices in the breast-feeding infant. There is no consensus with respect to infant monitoring, although a conservative approach warrants monitoring of those indices that are potentially affected by the individual medications. It would be prudent to establish a baseline and to periodically repeat such measures. Like the antidepressants, all mood stabilizers studied to date cross the placental barrier. Typically, anticonvulsant and lithium exposure in pregnancy is greater than 80 and breast-feeding exposure is considerably less. In summary, the literature on antidepressants and mood stabilizers has grown considerably in recent years. There is no evidence that antidepressants pose an acute risk to nursing infants. The mood stabilizers present a more complex issue with respect to both acute safety and the need for infant monitoring. Pending the completion of long-term follow-up studies specifically targeting...

Risk and Course of Bipolar Disorder During Pregnancy

Grof and colleagues (2000) presented findings suggestive of an apparent protective effect of pregnancy on the course of lithium-responsive type I BD. They described a benign course, and even improvement, during pregnancy, basing their results on comparisons made before and after pregnancy in women whose illness could be managed for prolonged periods without mood-stabilizing medication. Although these findings were proposed to support the view that pregnancy may prevent recurrences of BD, the sample may not have been representative of broader groups of women with BD (Viguera et al. 2002b). Moreover, other recent research and growing clinical experience suggest that pregnancy probably does not consistently protect against recurrences of mania or major depression in women with BD rather, it is often a time of substantial risk of relapse, particularly following discontinuation of ongoing mood-stabilizing maintenance treatment (Blehar et al. 1998 Finnerty et al. 1996 Viguera et al. 2000)....

21112 Benzodiazepines

When strictly indicated, benzodiazepines are among the drugs of first choice for the treatment of anxiety and sleeping disorders during pregnancy. They should be given at the lowest possible dose for the minimum amount of time. For long-term treatment, antidepressants are preferred. Long-acting benzodiazepines should be avoided. Observation of the neonate for respiratory depression, withdrawal symptoms or adaptation problems is recommended when benzodiazepines have been used up to delivery.

3 Treatment Of Postpartum Mood Disorders

Table 7 summarizes the breast-feeding safety profile of antidepressants most frequently used to treat depression. The relatively extensive literature focusing on selective serotonin reuptake inhibitors (SSRIs) in nursing indicates that most infants can continue to nurse when their mothers are prescribed these agents without risk of adverse events. Significantly less is known about the safety of venlafaxine or bupropion in nursing infants. Although the older antidepressants such as the tricyclics are not included in Table 7, they appear to be relatively safe for use during nursing (98). However, these agents pose more side effects for the mother and are no longer considered to be first-line treatments for depression (99-115). As stated earlier, the treatment of PPD is currently based on standards for nonpuerperal depression because there are no double-blind, placebo-controlled studies of antidepressants in the treatment of MDD with post-partum onset. There is some reluctance on the...

Psychotherapeutic and Pharmacotherapeutic Interventions

Because postpartum blues are characteristically mild in severity and resolve spontaneously, no specific treatment, other than support and reassurance, is indicated. Although the symptoms may be distressing, they typically do not affect the mother's ability to function and to care for herself or her infant. Psychiatric consultation is generally not required however, if the symptoms are severe or persist longer than 2 weeks, the patient should be evaluated to rule out the presence of a more significant depressive illness. For women with histories of recurrent affective illness, the blues may herald the development of a more significant PPD (O'Hara et al. 1991b Paykel et al. 1980). Although PPD is relatively common, few studies have systematically assessed the efficacy of nonpharmacologic and phar-macologic therapies in the treatment of this disorder (for reviews, see Dennis 2004 Dennis and Stewart 2004). There are no data to suggest that PPD should be managed differently from...

53 Reported Adverse Outcomes 531 Poor Neonatal Adaptability

Given that at least 50 of pregnancies are unplanned (102,135), many women first become aware of their pregnancies well into the first trimester. These women may abruptly discontinue taking all medications, including antidepressants, in attempts to minimize drug exposure to their fetuses. Einarson and colleagues interviewed 36 pregnant women 1 mo after they received counseling regarding the safety of antidepressant use in pregnancy (136). They found that 34 of these women discontinued their medication abruptly (28 on the advice of their health care providers). Of these women, 26 (70.3 ) reported deteriorating physical and psychological health. Eleven of these women reported suicidal ideation, and 4 were hospitalized. Abrupt discontinuation of certain antidepressants may be associated with a discontinuation syndrome, characterized by any or all of the following nausea and vomiting, diarrhea, diaphoresis, hot or cold flashes, tremors, excess lacrimation, syncope, anxiety, panic attacks,...

1913 micronutrients and postpartum depression 19131 Iron

Although the role of iron status remains unclear with respect to postpartum depression, current investigations point to increased risk for postpartum depression in women who have anemia 80, 81 . Corwin and colleagues 80 measured hemoglobin levels at 7, 14, and 28 days postpartum and depressive symptoms using the Center for Epidemiological Studies-Depressive Symptomatology Scale (CES-D) at 28 days postpartum. Hemoglobin levels on day 7 were negatively correlated with CES-D scores obtained on day 28 postpartum. Further, Beard et al. 81 demonstrated that iron treatment resulted in a 25 improvement in previously iron deficient mothers' depression and stress scales. Anemic

Kimberly Ragan MSW Zachary N Stowe MD D Jeffrey Newport Md Ms Mdiv

In this review, we provide a critical appraisal of literature on the use of antidepressants and mood stabilizers in lactating women, particularly with respect to determining nursing infant exposure. To expand beyond previous reviews, we have included recommendations from the Physicians' Desk Reference (PDR) and the American Academy of Pediatrics Committee on Breast Feeding (AAP).

Postpartum Mood Disorders

The postpartum period has clearly been defined as a time of increased vulnerability to psychiatric illness in women. In one of the most frequently cited studies of postpartum psychiatric illness, Kendell and colleagues (1987) demonstrated that women experience a dramatic increase in their risk of severe psychiatric illness in the first 3 months after the birth of a child. During the postpar-tum period, up to 85 of women experience some type of mood disturbance (Henshaw 2003). Most of these women experience the transient and relatively mild mood symptoms called the blues. About 10 -15 of women experience a more disabling and persistent form of mood disturbance, either postpartum depression (PPD) or postpartum psychosis (G.L. Cooper 1989 P.J. Cooper et al. 1988 Cox et al. 1993). Although postpartum mood disorders are relatively common, depressive symptoms emerging during the postpartum period are frequently overlooked by patients and their caregivers (Coates et al. 2004 Evins et al....

Unipolar Depression

(approximating 10 ) in gravid and nongravid women (O'Hara et al. 1990). Several other studies have also noted high rates of clinically significant depressive symptoms during pregnancy (Gotlib et al. 1989 O'Hara 1986, 1995). Data from a large-scale cohort study of 14,000 women suggested that antenatal depressive symptoms may be more common than postpartum depression (Evans et al. 2001). A personal history of affective illness significantly increases the risk of antenatal depression (Gotlib et al. 1989 O'Hara 1995) however, for about one-third of the women who become depressed during pregnancy, this represents the first episode of major depression (O'Hara 1995). Other risk factors for antenatal depression include marital discord or dissatisfaction, inadequate psychosocial supports, recent adverse life events, lower socioeconomic status, and unwanted pregnancy (Gotlib et al. 1989 O'Hara 1986, 1995). Women with recurrent major depression who have been maintained on an antidepressant...

31 Risk Factors

Numerous risk factors have been identified for prenatal depression. Those most commonly observed are previous depressive illness, lack of social support, negative life events in the preceding pregnancy (26), negative attitudes toward pregnancy, unplanned or first pregnancy, physical discomfort (e.g., nausea), and previous stillbirth (27,28). Additionally, poor prenatal care, poor marriage dynamics, remarriage, and substance abuse dependency have also been identified as risk factors for depression in pregnancy (29-31). topic have yielded conflicting results. One study that examined mood in a group of depressed pregnant patients during the first trimester noted improvements in mood over the second and third trimesters of pregnancy (46), whereas the results of a second prospective study showed depressive symptoms to be at their height in the third trimester (34-38 wk) (47). Further study in this area is ongoing.

43 Substance Abuse

Although a causal relationship between depression and substance abuse has not been clearly elucidated, the connection between depression and substance abuse (especially smoking and alcohol use) is of note. Depression during pregnancy is significantly associated with prenatal substance abuse. Finnish studies have found substance abuse to be co-morbid with depression in 6.4 of women (56). Also, in a recent US study of 186 pregnant women, 8 were found to have both psychiatric illnesses and substance abuse disorders (57). More critically, a study of1014 women of low SES showed depressive symptoms (as per CES-D scores > 16) to be significantly associated with smoking, as well as alcohol and cocaine use (57a). Alcohol consumption, smoking, and street drug use have been clearly associated with neonatal morbidity and mortality when used or consumed in even small to moderate amounts during pregnancy (9).

4 Conclusion

The pathogenesis of PPD is not well elucidated, and treatment studies focusing specifically on depression during the puerperium are scant at best. Thus, at the present time treatment of PPD and other mood disorders during the postnatal period are based on treatments for nonpuerperal depression and psychosis. Luckily, most of the antidepressants and anxiolytics used as first-line treatments appear to be relatively safe for the nursing infant. A challenge for the future will be to develop safe methods for critically evaluating the efficacy of medications and or hormones in postpartum depressed women who may or may not be nursing. In addition, future studies of the pathogenesis of postpartum mood disorders must begin to focus on the hormone neurotransmitter interface as well as factors, such as genetics, that mediate individual vulnerability to mood disorders during this special time in a woman's life.

Conclusion

Mood and anxiety disorders occur commonly during pregnancy, and women with recurrent illness appear to be at high risk for relapse, particularly if maintenance treatments are decreased or discontinued. While the use of psychotropic medications during pregnancy understandably raises concerns, there are data to support the use of certain antidepressants, including fluoxetine, citalopram, and the tricyclic antidepressants. Data on the newer selective serotonin reuptake inhibitor antidepressants are gradually accumulating and are encouraging. None of the SSRIs or TCAs

52 Pharmacotherapy

The literature on the pharmacological treatment of anxiety disorders occurring in pregnancy and the postpartum is very limited what is available focuses on treatments of panic disorder and OCD. A larger body of literature has developed on the treatment of depression during pregnancy and in the puerperium. It is from this work that most of the available information regarding the use of antidepressant medication of the selective serotonin reuptake inhibitor (SSRI) type in the perinatal period is gleaned. Because this class of medications is easy to administer and carries a low risk oftoxicity in overdose, the SSRIs are recommended as first-line pharmacological treatments for PPD (52), as well as for postpartum panic disorder and OCD (53). A growing controversy is the possibility of perinatal syndromes related to SSRI use during the third trimester of pregnancy. In Summer 2004, based on the recommendation of the Pediatric Advisory Subcommittee of the US Food and Drug Administration...

2102 Benzodiazepines

Carbamazepine has structural similarities to tricyclic antidepressants, and is used for grand-mal epilepsy, focal and psychomotor seizures, and trigeminal neuralgia. The anticonvulsive action of carbamazepine, similar to that of other AEDs, can be explained as a membrane-stabilizing action. Carbamazepine is well-absorbed when given orally, binds strongly to proteins, and has a plasma half-life of 1-2 days. In the fetus, carbamazepine reaches 50-80 of the maternal concentration.

2224 Medicines

Antidepressants Tricyclic antidepressants like amitriptyline and dothiepin can cause severe maternal toxicity, including cardiac arrhythmia and seizures, In another study, an overdose of the selective serotonin reuptake inhibitor (SSRI) fluoxetine was ingested in 21 pregnancies 16 of these were exposed in the first trimester. Among these, 13 infants were normal and 3 demonstrated anomalies - 1 cavernous hemangioma, 1 birthmark on the left cheek and an ear tag, and 1 severe CNS defect. However, a causal relationship cannot be established because all three pregnant women took multiple drug overdoses (McElhatton 2001). In the meantime, the NTIS in Newcastle has collected data on 160 pregnancies with overdoses of antidepressants that do not reveal any evidence of specific effects (McElhatton, personal communication 2003).

Course and Prognosis

The duration of postpartum illness appears to be variable. Puerperal episodes are often relatively short-lived and may last no more than 3 months (Cooper and Murray 1995). Many women, however, have a more prolonged illness, and several studies suggest that depressive episodes tend to be longer and more severe in those with histories of major depression (Cooper and Murray 1995 Goodman 2004). Some reports suggest that duration may be related to the severity of illness (Horowitz and Goodman 2004). In general, women with postpartum mood disorders have a good prognosis. In about half of the cases, puerperal depression or psychosis represents the first onset of a recurrent psychiatric illness (O'Hara 1995). Although there appears to be a subpopulation of women who have only puerperal episodes of psychiatric illness, the majority of women with a postpartum affective disorder will go on to have episodes of psychiatric illness unrelated to pregnancy or childbirth (Robling et al. 2000). Rates...

Depression

Normal emotional changes following childbirth may mask or be mistaken for depressive symptoms. 'Postnatal blues' are experienced by 50-80 of women, are transient and occur 3-10 days after delivery6,7. They are characterised by irritability, tearfulness, low mood, euphoria and sleep disturbance. They resolve spontaneously and the woman and her family need reassurance and support.

1910 screening

The Postpartum Depression Screening Scale (PDSS) is a survey available to clinicians for screening 8 . This self-report scale consists of 35 items that assess the presence, severity, and type of postpartum depressive symptoms. It has a five-point Likert response format in which women are asked to respond to statements about how they have been feeling since delivery. The response options range from 1 strongly disagree, to 5 strongly agree (Table 19.1). Agreement with a statement indicates the mother is experiencing that depressive symptom. The PDSS consists of seven symptoms content scales Sleeping Eating Disturbances, Loss of Self, Anxiety Insecurity, Guilt Shame, Emotional Lability, Mental Confusion, and Suicidal Thoughts. The range of possible scores is 35-175. A cutoff score of 80 or above indicates a positive screen for postpartum depression and the need to refer the mother for a formal diagnostic evaluation by a mental health clinician. Using this cutoff score of 80, Beck and...

10 Postpartum Issues

One issue of great concern is PPD (40). The prevalence of clinical depression in the postpartum period in the general population is estimated to be approx 12 (41). Franko et al. (22) reported more than three times that rate (35 ), an elevation that is consistent with the findings of earlier studies (7,17). In this prospective study a higher frequency of PPD was found in the group of women who were symptomatic with eating-disorder symptoms during pregnancy (22). Nearly half of the symptomatic group reported PPD, which may have been a function of previous affective disorder and or the physiological and psychological stresses of having an active eating disorder during pregnancy. Similarly, Morgan et al. (7) found one-third of a sample of 94 bulimic women to have PPD. It is noteworthy that in the bulimic women with a history of AN, two-thirds were diagnosed with PPD. Abraham (17) reported that 9 of 26 women with BN were treated for PPD, with 7 of those 9 having had eating-disorder...

1914breastfeeding

Breastfeeding is known to be very beneficial to both mother and infant, and recent reports suggest that it may reduce risk for postpartum depression in women by reducing stress 92-97 . Although the majority of investigations point to breastfeeding as protective in postpartum depression, results are equivocal, as other investigations have reported no relationship between depressive symptoms and breastfeeding 98-100 . As earlier described, Infants of mothers with postpartum depression are at risk for cognitive and emotional impairments 37-41 , and breastfeeding can help protect infants against these negative outcomes. Breastfed infants of depressed mothers exhibited decreased depressive symptoms compared to those who were bottle fed 101 .

Types of depression

This is a non-psychotic depressive disorder, which develops during the first year following childbirth and varies in its severity, with symptoms including exhaustion, irritability, difficulty sleeping and physical 'flu-like symptoms. It occurs in 10-15 of new mothers and often begins within 2 weeks of delivery (Kendell 1985). It is often unrecognised or misdiagnosed, though the majority of women recover spontaneously with time.

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