XXXX香港理工大学冬季培训班酒店管理

PerinatalMoodandAnxietyDisordersCortA.Pedersen,M.D.UNCDepartmentofPsychiatryPrevalenceofPerinatalDepressiveandAnxietyDisordersDepression:approximately14%withinthefirst2-3monthspostpartum(similarrateduringpregnancy).HalfmeetDSM-IVcriteria,halfRDCcriteria.Anxiety:Atleast14%inpostpartumperiodcombiningpanicdisorder,OCDandgeneralizedanxietydisorder.Byfar,themostcommonseriousmedicalcomplicationsoftheperinatalperiod.ObstaclestoRecognitionandTreatmentofPerinatalMood/AnxietyDisordersHighexpectationsofjoy&happinesswithnewbaby:cognitivedissonanceifdysphoricsymptomsarise.Attributionofdysphoriatostress,notassessinghallmarksymptoms.Selfblame.Lackofknowledgeaboutmoodandanxietydisorders.Criticalroleofantenataleducation.CommonDysphoricEmotionalExperiencesinNewMothersMoodlability-bluesandeuphoria.Oftenunanticipatedandsometimesoverwhelmingstressofnewborncare:lossofcontrolofone’stime,feelingtrapped,“WhydidIdothis?”Heightenedanxietyduetohyper-vigilanceaboutthebaby’swelfare.Delayedfeelingsofloveforthebaby.DiagnosingPerinatalDepression:

HallmarkPsychologicalSymptomsDepressivemood,sadness,tearfulness.Diminishedinterestorpleasureinmostactivities(especiallyintakingcareofthebaby).Feelingsofworthlessnessorinappropriateguilt(especiallyaboutbeinganinadequatemother).Recurrentthoughtsofdeathorsuicide.

EdinburghPostnatalDepressionScale:Coxetal.,1987,BrJPsychiatry150:782-6.

AmbiguousSymptoms

(oftenduetoperinatalphysiologicalchanges,

demandsofnewborn,notdepression)ChangesinappetiteorweightSleepdisruption(however,persistentinabilitytosleepwhenthebabyisasleepisacommonsymptominpostpartumdepression).Persistentfatigue.Psychomotorretardationoragitation.Diminishedsubjectiveperceptionofabilitytothinkorconcentrate.BiologicalRiskFactorsfor

PostpartumDepressionHistoryofpostpartumdepression(upto50%risk).Historyofdepressionnotassociatedwithpregnancy(upto25%risk).Depressivesymptomsduringpregnancy.Familyhistoryofdepression.Historyofpremenstrualdysphoricdisorder.Postpartumblues.

Dohormonesplayarole?Progesteroneandestrogenlevelsdropprecipitouslypostpartum.Cortisol,thyroidandotherlargehormonalshiftsalsooccur.However,hormonelevelsandchangesinlevelsdonotcorrelatewithmoodsymptoms.Butrecentresearchindicatesthatwomenwhogetperipartumdepressionaremoresensitivetohormonefluctuations(Blochetal.,2000AmJPsychiatry157:924-930).PsychosocialRiskFactorsforPerinatalDepressionLackofsocialsupport.Poorrelationshipwiththefatherofthebaby.Stressfullifeevents.Primiparity.Adolescence.

PostpartumDepressionPredictorsInventory-Beck,1998,JOGNN27:39-46.PostpartumAnxietyDisorders:

ClinicalCharacteristics

Panicdisorder:Intensefearofharm/harmingbaby.Palpitations,hyperventilation,sweating,etc Difficultycaringfor,leavingbaby.OCD:Intrusivethoughts/imagesofgrievousharmtobaby.Mothersometimesimaginesherselfinflictingharm.EffectsofPregnancyontheNaturalCourseofAnxietyDisorders

Panicdisorder:Increasedriskofrecurrenceorintensificationpostpartum.Obsessivecompulsivedisorder:ManywomenwithOCD(perhapsaround40%)haveinitialonsetofsymptomsduringpregnancyorthepostpartumperiod.PerinatalDepressionandAnxiety:TreatmentandProphylaxisStressreduction.Supportgroups.Psychotherapy:interpersonal,cognitive-behavioral,supportive.O’Haraetal.,2000,ArchGenPsychiatry57:1039-1045.

Medication:usualtxsaregenerallyveryeffective.SSRIsbestforprophylaxis.Estrogen?LighttherapyPre&PostpartumPrevalenceofPsychiatricAdmissionsamongWomenPostpartumPsychosis:

ClinicalCharacteristicsIncidence:1-2/1000,firstfewpostnatalweeks.90%+arepsychoticmooddisorders.Moodsymptoms:depression,mania,mixed,cycling.Suicidalimpulses.Psychoticsymptoms:hallucinations,delusions,thoughtdisorder.Delusion-basedhomicidal/infanticidalimpulses.Symptomsofdeliriumoftenpresent:disturbancesofconsciousness,attention,cognition,perception,fluctuationofsymptoms.RiskFactorsforPostpartumPsychosisHistoryofbipolarorschizoaffectivedisorder:riskincreaseswithnumberofpriorepisodesandprominenceofpsychoticsymptoms(perhapsuptoa50%risk).Historyofpostpartumpsychosis(50-75%risk).ManagementandTreatmentofPostpartumPsychosisManagement:Hospitalizeimmediately(psychiatricemergency!)Constant,closeobservationSupervisevisitswithbabyTreatment:Moodstabilizers(lithium,valproicacid)AntipsychoticsAntidepressants(ifprimarilydepressed)Benzodiazepines(agitation)ECT

PostpartumPsychosisProphylaxisMedication:Startmoodstabilizersimmediatelypostpartumorevenlateinpregnancy.Estrogen?General:Socialsupport/helpnetworkinplace.Patient/familyeducationaboutsymptoms.Planofactionifsymptomsdevelop.AssessingtheSafetyofPsychotropicMedicationsinPregnancy/LactationProspective,doubleblindstudiesdrugtrialsareunethical.Therefore,wearedependentoninformationfromcasereports,retrospectivechartreviews,animaltoxicologystudies.Bestsummariestodateofthisbodyofevidence:Wisneretal.,(2002)NEJM347:194-199;Newportetal.(2004)TheAPATextbookofPsychopharmacology,3rdEditionAssessingtheSafetyofPsychotropicMedicationsinPregnancy/Lactation-contAconsiderablebodyofevidenceaccumulatedoverthelast2decadesindicatesthatfetal/newbornexposuretomostclassesofpsychotropicmedicationisrelativelysafeevenduringthefirsttrimester.Mountingevidencethatstressduringpregnancy,includingthestressofuntreatedseverepsychiatricillness,hasadverseeffectsonfetaldevelopment.PotentialRisksofTreatmentwithPsychiatricMedications

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