Postpartum Depression

Adherence to long-term therapy for chronic illnesses in developed
countries averages 50%. In developing countries, the rates are even
lower.
Noncommunicable diseases (cancer, hypertension, diabetes,etc)
Mental disorders, human immunodeficiency virus/acquired
immunodeficiency syndrome and tuberculosis, together
represented 54% of the burden of all diseases worldwide in 2001
and will exceed 65% worldwide in 2020.
La Depressione : definizione
La depressione come fenomeno appare di non facile definizione,
in quanto legata indissolubilmente al concetto di umore.
L’umore è una dimensione complessa della vita psichica dell’uomo, nella
quale confluiscono aspetti emozionali, affettivo/sentimentali, cognitivi,
temporali, motivazionali e motori che, se così si può dire, “colora di sé”
tutta la vita dell’individuo, costituendo una sorta di griglia percettiva ed
elaborativa con cui si dà significato alla realtà.
(Vella, Siracusano1994)
La Depressione : definizione
Esiste una linea di continuità che collega la depressione
sia alla tristezza, esperienza comune e fisiologica,
sia al dolore, che rappresenta a sua volta uno dei nulei centrali
della depressione.
La qualità che fa traghettare dolore e tristezza nella depressione può
essere riconosciuta nella loro pervasività, nell’interessare psiche e soma
allo stesso modo, nella loro fissità, nel non essere più modificabili dalle
situazioni esterne, tristi o liete, nell’intensità del dolore, che tende a
congelare vissuti psichici e somatici in un unico blocco
privo di spinta evolutiva.
Depressione e suicidio
10-15% dei pazienti depressi si suicida
I due terzi tra i pazienti depressi hanno idee suicide
I pazienti depressi con aspetti psicotici considerano talvolta l’uccisione
di persone coinvolte nei loro sistemi deliranti
Population projection of US adults with
lifetime experience of depressive disorder
by age and sex from year 2005 to 2050 (I).
 In year 2006 the (weighted) prevalence of lifetime experience of
depressive disorder was 15.7% among 188,292 respondents aged 18
years or older.
 Female prevalence was 20.6%, which was about twice as high
as the prevalence among males (11%).
Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry. 2008 May 23. [Epub ahead of print]
Population projection of US adults with
lifetime experience of depressive disorder by
age and sex from year 2005 to 2050 (II).
 From year 2005-2050, the total number of US adults with
depressive disorder will increase from 33.9 million to 45.8 million,
a 35% increase.
 The increase is projected to be greater in the elderly population
aged >/= 65 years (3.8-8.2, a 117% increase???) than in the young
population aged < 65 years (30.1-37.7, a 25% increase).
Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry. 2008 May 23. [Epub ahead of print]
Depressione e suicidio
10-15% dei pazienti depressi si suicida
I due terzi tra i pazienti depressi hanno idee suicide
I pazienti depressi con aspetti psicotici considerano talvolta l’uccisione
di persone coinvolte nei loro sistemi deliranti
Gender differences in health status
• In industrialized countries males tend to die earlier
than females and females tend to have greater
longevity but higher rates of morbidity (Okojie, 1994;
Stein, 1997; Lewis, 1998)
• This female advantage is a relatively recent
phenomenon and female excess mortality, which
defined many western societies prior to the industrial
revolution, still pertains in many less developed
countries today ( Annandale, 1998)
Prevalenza della depressione
(National Comorbidity Survey)
Percentuale di Casi
30
25
20
Maschi
Femmine
15
10
5
0
ia
z
an
f
In
24
15
34
25
44
35
54
45
Classi di Etˆ
(anni)
64
55
Gender Differences in Prevalence of Major
Depression
Women: 1.5-2.5 X rate relative to men during ages 15-54
Kessler et al (1993) Journal of Affective Disorders
The rate of MD for women rises dramatically above that for men
during and after puberty (with two peaks - childbearing years and
perimenopausal transition) and then actually falls after menopause
Puberal status, puberal
timing,age, hormonal
mechanisms (Angold)
Difficulties with selfimage, temperament and
early sexuality (Stattin and
Magnusson)
New, hormonally driven
needs for affiliation,
difficulties with the
transition to adolescence 
negative life events
(Cyranowski)
Genetic loading  negative
life events (Silberg, Pickles, Rutter)
History of MD, traumatic
experiences, genetic factors,
temperament (Kendler)
Girls who lack healthy parental
attachmentsanxious or inhibited
temperament failed to develop good
coping skills (Cyranowski)
Reproductive Hormones and Neurotransmitters
Effects of Estrogen
•Synapse formation
•Activates mature neuronal cells
•Increases sensory perception
•Increases cerebral perfusion
•Augments central nervous system
glucose use
•Alters pain pathways
Differences between Males and Females in Rates of
Serotonin Synthesis in Human Brain
Nishizawa S, Benkelfat C, Young SN, et al.
Proc Natl Acad Sci USA 1997; 94 (10): 5308-13
DEPRESSIONE NELLA DONNA
Fasi
Vita
Fasi
FASI
vita
VITA
Problemi Collegati
Concentrazioni basse o
fluttuanti di ormoni serici
IPOTESI TEORICHE
Developmental
Life Events-Stress-Trauma
Ambiente Familiare
Contraccettivi
Fecondazione Assistita
Aborto
Pubertà-Fase Premestruale
Terapia
Gravidanza-Post Partum
Ormonale Sosti.
Menopausa
Gravi. Multi.
Temperamento
Cambiamenti Ormonali
Predisposizione Genetica
Pathways Depressione
Gender Differences in The Rates of Exposure to Stressful Life Events
and Sensitivity to Their Depressogenic Effects
Stressful Life Events
Assault
Divorce or separation
Financial problems
Housing problems
Illness
Job loss
Legal problems
Loss of confidant
Marital problems
Robbery
Work problems
Proximal network event:
Problems in getting alone
Crisis
Death
Illness
Distal network event:
Problems in getting alone
Death
Illness
Kendler KS, et al., 2001
Gender Differences in The Rates of Exposure to Stressful
Life Events and Sensitivity to Their Depressogenic Effects
Conclusion
Women reported more interpersonal whereas Men reported more
legal and work -related stressful life events.
Most life event categories influenced the risk for major depression
similarly in the two sexes
The greater prevalence of major depression in women versus men
is due neither to differences in the rates of reported stressful life
events nor to differential sensitivity to their pathogenic effect.
Kendler KS, et al., 2001
Gender and the Frequency of
Stressful Life Events
Male preponderant:
Female preponderant:
• Housing problems,
• Job loss,
• Loss of confidant,
• Legal problems,
• Problems getting along with and crises
• Robbery
involving individuals in their proximal
• Work problems
network
• Illness of an individual in their distal
network
No or inconsistent gender difference:
financial or marital problems, illness, illness of individual in in one’s
proximal network, and problems getting along with and death of an
individual in one’s distal network
Kendler KS, et al., 2001
Gender and Sensitivity to
Depressogenic Effect of Stressful Life Events
Male-sensitive:
•
•
divorce or separation
work problem
Female-sensitive:
•
problems getting along with and
•
death of an individual in their
proximal network
No or inconsistent gender difference
across samples, no consistent and significant gender differences were
seen in the sensitivity to the remaining 15 event categories
Kendler KS, et al., 2001
 PREVALENCE OF
MD IN WOMEN
 Vulnerability/Exposure
to Stressful Life Events
 Genetic Loading
Life Cycle in Women
HPG
Axis
Reproductive
Modulation Of The Neuroendocrine System
by Fluctuating Gonadal Hormones
Neuromodulators
Psychological
Puberty
Adolescence, Sexuality, Maternity,
Lifestyle, “Empty-nest syndrome”
Menopause
Longitudinal View of Depressive Illnesses Across
Women’s Lives
Menarche
Premenstruum
Pregnancy
Postpartum
Menopause
Depression as a function of reproductive related
transitions in women
Condition
Reproductive Transition
Premestrual syndrome
Luteal phase of the menstrual cycle
Premestrual dysphoric disorder
Luteal phase of the menstrual cycle
Depression in pregnancy
Postpartun “blues”
Antepartum months
First 2 postpartum weeks
Postpartum depression
First postpartum month (up to first 3 pp.
month)
Postpartum psychosis
First postpartum month, especially first 2
pp. weeks
Perimenopausal depression
5-7 years prior to menopause
POSTPARTUM DEPRESSION
Depression as a function of reproductive related
transitions in women
Condition
Frequency
Premestrual syndrome
Up to 80% of naturally menstruating
women
Premestrual dysphoric disorder
3%-8% of naturally menstruating
women
Depression in pregnancy
Postpartun “blues”
No altered risks for MD. 20% of
pregnant women may have minor
depressive symptoms
50%-80% of postpartum women
Postpartum depression
10%-22% of postpartum women
Postpartum psychosis
0.1 % of postpartum women
Perimenopausal depression
exact frequency unknown due to
sources of inconsistency across studies
(i.e.definition of menopause status)
Postpartum Depression: what it’s not
Postpartum depression has been used as a catchall
phrase for many disorders, but it’s important to
differentiate it from other postpartum disorders:
•
Maternity Blues
•
Postpartum panic disorder
•
Postpartum obsessive-compulsive disorder
•
Postpartum bipolar II disorder
•
Postpartum posttraumatic stress disorder
•
Postpartum psychosis
(Beck, Cheryl Tatano DNSc, CNM, FAAN, American Journal of Nursing, 2006; 106 (5) 40-50)
Postpartum Depression: what it is
Postpartum Depression is a major depressive disorder. It strikes about
1 in 10 women.
Depressed Mood or Loss of Interest or Pleasure with 5 or more of the
following symptoms for at least two week:
1) insomnia or hypersomnia, 2) psychomotor agitation or retardation, 3)
fatigue, 4) changes in appetite, 5) feelings of worthlessness or guilt, 6)
decreased concentration and suicidality.
Although the DSM-IV-TR states that the depressive episode begins
within four weeks of birth, many clinicians and researchers agree that
this description is too limiting, as it’s thought that postpartum
depression can occur up to a year after childbirth.
RISK FACTORS Associated With The
Development of Postpartum Mood Disorders
Were found to be significant risk factors for postpartum mood disorders:

Premenstrual Dysphoric Disorder (PMDD)

Mood symptoms during past oral contraceptive use

A past history of depression

Mood symptoms during the first 2-4 days postpartum
Bloch M et al. J Affect Disord. 2005; 88 (1): 9-18.
Two recent metaanalyses have identified significant
risk factors for Postpartum Depression

Prenatal depression
 A history of depression

Low self-esteem

Difficulties with child care
 Difficult infant temperament

Prenatal anxiety

A high stress level
 Single marital status

A low level of social support
 Low socioeconomic status

Poor marital relationship
 Unplanned or unwanted
pregnancy
 Maternity blues
Beck, Cheryl Tatano DNSc, CNM, FAAN, American Journal of Nursing, 2006
A History of Depression
Mood Symptoms During
Past Oral Contraceptive
Use
Low a low level of social
support-socioeconomic
status
PMDD
Single marital status-Poor
marital relationship
Unplanned or unwanted
pregnancy
Multiple Birth
Cesarean Surgery
Assisted Conception
Maternity blues
POST PARTUM DEPRESSION
Population projection of US adults with
lifetime experience of depressive disorder by
age and sex from year 2005 to 2050 (III).
CONCLUSIONS
By year 2050, approximately 46 million US adults aged 18 years
Or older will be diagnosed with a depressive disorder. The increase
will be more pronounced in adults aged 65 or older. Prevention,
detection, and treatment of depressive disorders might attenuate
the magnitude of this estimate.
Heo M,, Murphy CF ET AL.Int J Geriatr Psychiatry. 2008 May 23. [Epub ahead of print]
Il problema della diagnosi : Esiste una
“Depressione dell’anziano” ?
Classificazione dei Disturbi
dell’Umore secondo il DSM-IV TR
296.xx Disturbo Depressivo Maggiore
.2x Episodio Singolo
.3x Ricorrente
300.4 Disturbo Distimico
311
Disturbo Depressivo NAS
LA PRESENTAZIONE CLINICA DELLA
DEPRESSIONE NELL’ANZIANO
Most common clinical features
1. Una restrizione di competenze e abilità sociali, in seguito ad una
crescente multi-morbidità, isolamento sociale, solitudine, perdita
del partner e dei parenti, nelle sindromi depressive reattive”
(Müller-Spahn et al, Gerontology 1994)
2. “Diffuse e mutevoli lamentele somatiche, ansia e agitazione
psicomotoria nelle sindromi depressive endogene ” (MüllerSpahn et al, Gerontology 1994)
3. Comorbidità con disturbi d’ansia : disturbo di panico, fobie
specifiche, fobia sociale (Lenze et al., Am J Psychiatry 2000)
LA PRESENTAZIONE CLINICA DELLA
DEPRESSIONE NELL’ANZIANO
Most common clinical features
4) Hopelessness (Joiner et al, J Affect Disorder 2007)
4) Disforia e disturbi dell’appetito: sintomi prodromici (Berger
et al, Am J Psychiatry 1998)
6) Più lenta risposta agli antidepressivi (Mandelli et al,
Psychiatry Res 2007)
PSEUDODEMENZA DEPRESSIVA vs ALZHEIMER
DATI ANAMNESTICI
Alzheimer Disease
Pseudodemenza Depressiva
 Evoluzione lenta e progressiva
 Evoluzione piuttosto rapida
 Nessuna storia significativa di
Depressione
Pregressi episodi di tipo
depressivo