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Perinatal Mental Health
Certification Exam
Questions With 100%
Correct Answers | Updated
Risk Factors for Perinatal Psychosis 1st baby; stopping mood stabilizer; obstetric complications; perinatal/neonatal loss; previous bipolar/psychosis; family history; sleep deprivation 3 Biggest fears of panic disorder dying; losing control; going crazy Maternal Mortality Rate (all women) 1,200/year or 14.4/1, Maternal Mortality Rate (black women) 43.5/1, Prevalence of PP PTSD 9% % of bipolar symptoms that relapse without medications 70% Prevalence of PP Psychosis 1 - 2/1, Prevalence of PPD in Fathers 10% Prevalence of PP Anxiety 8 - 20% Prevalence of prenatal anxiety 15% Prevalence of PP depression 21%
Prevalence of PP panic disorder 11% Prevalence of PP OCD 11% PP PTSD Themes
- lack of caring 2) poor communication 3) feeling powerless 4) do ends justify means Maternal Mortality 1,200 with complications that are fatal; 60,000 complications that are near fatal PP Psychosis Clinical Features (onset) <2 weeks PP PP Psychosis Clinical Features (cognition) decreased concentration, decreased sensations, disorientation PP Psychosis Clinical Features (behavioral) agitated, hyperactive, distant, aloof, decreased self care PP Psychosis Clinical Features (Mood) labile, elated, and dysphoric PP Psychosis Clinical Features (Speech) Rambling Psychotic Thoughts delusions, ego-syntonic thoughts OCD Thoughts Parents don't want to harm baby, no delusions/hallucinations, parents have taken steps to protect baby DSM-5 Criteria for PTSD qualify for four categories
- stressor 2)Intrusions 3)Avoidance 4)Negativity in cognition/mood 5)arousal Causes of Birth Trauma
2 days - 2 weeks/birther PP substance abuse 40 - 49% alcohol; 4.5-8.5% marijuana
infants born to depressed mothers
400, PMAD Prevalence 1/5-7 women; 1/10 men % of unplanned pregnancies 50% Prevalence of first dx of BPD PP 50% Substance use in pregnancy 5.4% women use elicit drugs; 14.6% adolescent moms alcohol use in pregnancy 8.5% women Prevalence of psychosis in women with known BPD 20 - 30% Exacerbating Factors for PMAD's lack of sleep; physical pain and or inflammation; unresolved grief and or loss; complications in pregnancy; health challenges in baby or parents; temperament of baby; age related stressors; perfectionism/high expectations Risks of Stillbirth - tobacco 1.8 - 2.8x more likely Risks of stillbirth - marijuana 2.3x more likely Risk of stillbirth - stimulant or prescription pain reliever 2.2x more likely AAP recommendations - breastfeeing human milk exclusively for 6M Relationship between breastfeeding and PMADs
breastfeeding and depressions are a bi-directional relationship; breastfeeding may support maternal mental health; exclusively breastfeeding women may be less likely to be depressed; depression leads to lower breastfeeding rates and earlier cessation Hormones and Lactation depression suppresses the two hormones essential to lactation: prolactin and oxytocin Additional causes of oxytocin suppression C-section; stressful or traumatic labor/birth; epidurals Reglan medication to increase milk supply; increases risk of depression by 7x Race and Breastfeeding black infants consistently had the lowest rates of breastfeeding initiation and duration across all study years Apps to support breastfeeding and medication Mother to Baby; Infant Risk; LactFacts Teen birth rates 18.8/1, Medical risks for teenage mothers high blood pressure; anemia; nutritional deficiencies; early labor; LBW; sexually transmitted infections; higher rates of infant mortality; obstructed labor PMAD risk factors in Adolescent Mother's untreated depression in their mother or primary caregiver; social isolation and peer rejection; weight/shape disturbance; low maternal self efficacy; family conflict; low self esteem; physical and sexual abuse Military PMAD Risk 3.4x/likely for PPD when spouse is deployed; 66% of military spouses "worried that looking for assistance for their own issues would harm their loved ones' chances of promotion" NICU + PMAD's 20 - 30% of NICU parents experience mental health disorders within a year PP PPD in NICU 25.5% to 63%
Screening effects on PPD reduces relative risk of continued depression at 3-5M by 18-59% screening outcomes reduce overall prevalence of depression, more readily identify those at risk and in need of further evaluation Who should screen? anyone who meets with child bearing families AAP standard of care screening 1,2,4 and 6M visit ACOG standard of care screening one time perinatal Annals of Family medicine standard of care screening 6 and 12 M PSI Screening recommendations first prenatal visit; once in second trimester; once in third trimester; 6 week PP OB visit; 6 and 12M at OB; 3,9,12M pediatric visits Key screening points offer privacy; be mindful of cultural consideration; self administered or filled out in waiting room; provide a brief explanation or cover sheet; make it part of standard practice (not unique); screening tools are not a substitute for clinical judgement evidenced based screening tools EPDS; PHQ - 9 EPDS available in 60 different languages; validated with teens, fathers and pregnant women; easy to administer and score EPDS Scores None or minimal depression (0-6) Mild Depression (7-13) Cut off scores (10-12, vary) Moderate depression (14-19) Severe depression (19-30) PHQ- 9 validated for prenatal use, multiple languages available
PPDS
35 items, takes 5-10 minutes, 3rd grade reading level, validated >2wks PP, english and spanish available EPDS And Bipolar 22% of women scoring >10 on EPDS had a diagnosis of bipolar 1 MDQ Mood depression questionnaire; improves dx of bipolar when used in conjunction with EPDS Trauma informed screening tools ACES, Urban ACES, Life Event Checklist, PCL-C, Impact of Events Scale- Revised ACE's Adverse Childhood Experiences ACEs score the higher the score the greater likelihood of severe and persistent emotional problems, health risk behaviors, serious social problems, adult disease and disability, high health and mental health care costs, poor life expectancy Trauma Informed Care Values listening and validation; promoting and sustaining safety; education and training; assessment of self; supporting consumer control; partnership and collaboration; ensuring cultural humility cultural competence cultural humility Racism and Physical health poorer mental health outcomes among communities of color Biological weathering chronic exposure to racism can dysregulate Key components of intake and history pregnancy history; prenatal and fetal history; medical history; newborn history; sleep hygiene; mental health history; social history; spiritual history Assessing for intrusive thinking caution around differentiating between scary thoughts and suicidal thoughts "my baby will be better off without me"
facilitator guides process and intervenes when needed; participants support each other, give feedback; usually open at all times to new members; support persons might be included Therapy group facilitator is a professional health or mental health provider; more focus on group dynamics and therapeutic process for each participant; closed group for specific time frame; might include group for couples Therapeutic factors of groups altruism, imitative behavior, interpersonal learning, group cohesiveness, existential factors, instillation of hope, universality, imparting information Group options format: open v. closed; screening participants; directive vs. non directive; fee schedule; time of day/evening; babies welcome; partners/families welcome? Creating a network: 6 steps of development
- brainstorming
- investigation
- planning
- implementation
- evaluation
- future endeavors 9 Steps to wellness
- education
- sleep
- nutrition
- exercise and time for yourself
- non judgmental sharing
- emotional support
- practical support
- referrals and other resources
- plan of action EBT approaches CBT, IPT, peer support (groups/telephone), psychoeducational group therapy, mother infant therapy and education Common psychotherapeutic goals changing identity; checking expectations with reality; reducing perfectionism and comparison; communication and conflict resolution; anger management; grief and loss resolution; supports and referrals for connection Road to Recover
acute symptoms > initial recovery > first slump > transient symptoms > resolving > recovering confidence > grieving > finding meaning CBT CBT teaches clients to identify, evaluation, and change dysfunctional patterns of thinking, resulting in mood and behavioral changes CBT efficacy CBT is effective for prevention and tx of perinatal dep and anxiety Mindfulness CBT the goal of MBCBT is to help individuals learn how to avoid relapses by not engaging in automatic thought patterns that perpetuate and worsen depression and learning to observe and accept ones own experience common components of CBT assertiveness training; fostering resilience; desensitization/exposure; cognitive restructuring cognitive restructuring identify automatic thoughts; connection between thoughts and feelings; evaluate thoughts/cognitive distortions; explore and modify underlying beliefs; develop alternate perspectives CBT tools relaxation, psycho=education, activity scheduling, behavioral rehearsal, questioning the evidence, mental imagery, de-catastrophizing, cognitive rehearsal, homework assignments Interpersonal Therapy based in attachment theory; depression occurs in the context of interpersonal relationships; IPT helps modify disrupted relationships or expectations; time limited therapy (12-16 weeks) IPT Strategies improve interpersonal communication to get ones needs met; developing a social support network; role playing; assertiveness skills; conjoint sessions with partner for communication analysis Three target areas for IPT
- what have I lost? (grief)
- where am I now? (role transitions)
- what do I need? (interpersonal role dispute) Attachment and Parent-Infant Therapies
greater use of alcohol; less healthy nutrition; higher BMI; less participation in prenatal care; reduced length of breastfeeding long term effects of untreated PMAD on infant more emotional problems and temperaments; more behavioral problems; reduced cognitive functioning; exaggerated neuropsychological and emotional responses to stress Potential concerns regarding medication use in pregnancy congenital malformations; pregnancy loss; excessive bleeding; gestational hypertension; gestational DM; preterm labor; LBW; neonatal side effects; neonatal pulm HTN; autism; long term neurobehavioral effects Timing of exposure: first trimester physical teratogenicity timing of exposure: second trimester behavioral teratogenicity timing of exposure: third trimester physiologic dev; effects on growth; effects on labor timing; neonatal side effects antidepressants and perinatal loss no increased risk of perinatal loss antidepressants and preterm birth average reduction in gestational age is 2-4 days with antidepressant exposure antidepressants and LBW antidepressant exposed babies weight, on average, 97 grams less than unexposed babies antidepressants and neonatal loss 10 - 30% of pregnancies; severe in less than 3% antidepressants and PPHTM 5.4/1,000; risk is only found with serotonergic antidepressants antidepressants and gestational hypertension small increased risk of pregnancy related hypertensive disorders Better studied antidepressants prozac (fluoxetine); zoloft (sertraline) not well studied antidepressants
vilazodone (viibryd); levomilnacipran (fetzime); vortioxetine (trintellex) Paxil (paroxetine) increased risk of cardiovascular malformations; FDA cautionary about use during pregnancy tricyclic antidepressants well studied; no congenital malformations; no adverse neurobehavioral outcomes; more significant maternal side effects - constipation and sedation Considerations for Antidepressants Choices PP avoid excessive sedation; sleep interference; weight gain; sexual dysfunction; breastfeeding exposure additional perinatal treatment options ECT; transcranial magnetic stimulation (less studied) Brexanolone only FDA approved medication for PP depression; IV over 60 hours; works quickly; expensive Benzodiazepines no significant increased risk of major malformation; increased risk of preterm birth; associated with fetal toxicity; neonatal toxicity; and neonatal withdrawl Hypnotic Benzodiazepine Receptor Agonists zolpidem, zopiclone, zalepon; no increased risk of malformations; increased rates LBW and preterm birth Buspirone (Buspar) increases serum prolactin; no studies during pregnancy; no studies about breastfeeding Mood stabilizers during pregnancy discontinuing mood stabilizers leads to high recurrence rates during pregnancy Carbamazepine (tegretol) increased risk of neural tube defects; probably not behavioral teratogenicity; decreased neonatal size Carbamazepine - Guidelines to reduce risk supplement folate and during pregnancy; administer vitamin K to the newborn per pediatric recommendations; ultrasound during neural tube formation Perinatal Use of Stimulants
range: 50-200+mg clinical pearls: most commonly prescribed in pregnancy and PP, GI distress common at initiation - diarrhea, nausea Descenlafaxine (Pristiq) SNRI starting does: 25mg range: 50 or 100mg clinical pearls: little safety data on use in pregnancy and lactation Duloxetine (Cymbalta) SNRI starting dose: 20mg range: 60-120mg clinical pearls: very little safety data on use in pregnancy and lactation Venlafaxine (Effexor) SNRI starting does: 25mg range: 75-300mg clinical pearls: XR formulation most used, use for steady state does; short half life; notable withdrawal effects; monitor BP; most safety data in pregnancy/lactation of SNRI class Bupropion (Wellbutrin) Not 1st line Starting dose: 75mg, 150mg range: 100-200mg, 150-300mg clinical pearls: XL preferred, augmentation for partial response to SSRI, activating does in AM always; do not use in pts with h/o eating disorder or sz, not associated with precipitating with mania Mirtazapine (Remeron) not 1st line starting does: 7.5mg Range: 15-60mg Clinical pearls: inverse relationship b/w dose and sedation, used for insomina, hyperemesis gravidarum, stimulates appetite Vortioxetine (Trintellix) Not 1st line starting dose: 5mg range: 5-20mg clinical pearls: new medication, limited to no safety data, would not initiate in pregnancy or PP but don't stop is already stable, sedating, notable nausea at initiation
Buspirone (Buspar) Anxiolytic (non benzo) starting dose: 5mg range: 5-60mg clinical pearls: dosing BID or TID, preferred over benzodiazepines in pt w h/o substance abuse/dependence, not always effects, minimal data in pregnancy/lactation Hydroxyzine (Vistaril) anxiolytic (non benzo) starting dose: 25mg range: 25-50mg clinical pearls: dosing BID-QID, antihistamine Quetiapine (Seroquel) anxiolytic (non benzo) Starting does: 12.5mg Range: 25-100+mg clinical pearls: atypical antipsychotic, low doses effective for insomnia and anxiety, increase in weight gain, doses >100mg for bipolar and psychotic disorders, orthostatic hypotension common first few mornings Alprazolam (xanax) anxiolytic (benzo) starting dose: .25mg range: 0.25mg - 2mg clinical pearls: only for use in acute, discrete panic symptoms, prn, most addictive, short half life, notable rebound anxiety, AVOID when possible Clonazepam (Klonopin) anxiolytic (benzo) starting dose: .25mg range: .25-2mg clinical pearls; longest half life, can use q12h dosing Lorazepam (ativan) anxiolytic (benzo) starting dose: .5mg range: .5 - 2mg clinical pearls: can dose BID - tID, no active metaboliets Diphenhydramine (Benadryl) Sleep aide starting dose: 25mg Range: caps at 50mg
atypical antipsychotic starting dose: .5mg range: .5-5mg clinical pearls: can help with sleep, can cause hypolactinema, weight gain in higher doses Aripiprazole (Abilify) atypical antipsychotic starting dose: 5mg range: 5-30mg clinical pearls: may need to monitor glucose with any atypical antipsychotic, good for anger and impulsivity, augment with depression Ziprasidone (Geodon) atypical antipsychotic starting dose: 40mg BID range: 40-160mg clinical pearls: not much data in pregnancy or lactation Olanzapine (Zyprexa) atypical antipsychotic starting dose: 2.5mg range: 5-20mg clinical pearls: check blood sugars, can increase fatigue/dizziness, hypolactinemia Haldol (haloperidol) typical antipsychotic starting dose: .5mg range: .5-5mg clinical pearls: not often used in pregnancy unless needed with psychosis to sedate Lamotrigine (Lamictal) Antiepileptic starting dose: 25mg range: 100-200mg clinical pearls: stephens johnsons syndrome, few side effects and tolerated well, may need to be increased in pregnancy and secondary to fluid changes in 3rd trimester Valproic Acid (Depakote) antiepileptic starting dose: 250mg range: 250-500mg TID clinical pearls: known teratogen, do not use unless only medication that has
worked, do not start in women in reproductive age, black box warming in pregnany carbamezepine (Tegretol) antiepileptic starting dose: 200mg range: 800-1200mg clinical pearls: contraindicated in pregnancy, SJS, teratogen neural tube defects, neurodevelopmental delay Bupropion - Effects on baby possible sz Citalopram - effects on baby uneasy sleep, drowsiness, irritability, weight loss, and restlessness Escitalpram - effects on baby enterocolitis fluoxetine - effects on baby excessive crying, irritability, vomiting, watery stools, difficulty sleeping, tremor, somnolence, hypotonia, decreased weight gain, reduced rooting, reduced nursing mirtazapine - effects on baby more rapid weight gain, sleeping through the night earlier paroxetine - effects on baby agitation, difficulty feeding, irritability, sleepiness, constipation setraline - effects on baby benign sleep myopclonus, transient agitation Alternative tx with promising evidence exercise/nutrition, yoga, massage, repetitive TMS, stress reduction techniques
