PERINATAL SUICIDE ANGELA STINNETT BSN, RN AND LUCY J. PURYEAR M.D. - PowerPoint Presentation

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PERINATAL SUICIDE

ANGELA STINNETT BSN, RN AND LUCY J. PURYEAR M.D.

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SUICIDE: DEFINITION AND FACTS

The World Health Organization (WHO) defines suicide as the act of killing oneself. The act must be deliberately initiated with the full knowledge, or expectation, of its fatal outcome

The World Health Organization (WHO) estimates each year approximately 1 million people die from suicide, that represents a global mortality rate of 16/100,000 or one death every 40 seconds. By 2020 the rate of death will increase to one every 20 seconds.

In the last 45 years suicide rates have increased by 60% worldwide. Suicide is now among the three leading causes of death among those aged 15-44 (male and female). Suicide attempts 20X > completed suicides.

Many adults think about suicide or attempt suicide.

Seriously thought about suicide: 9.8 million every year

Made a plan for suicide: 2.8 million every year

Attempted suicide: 1.3 million every year

Worldwide, 800,000 people die due to suicide every year

In North America Suicidal Ideation can be detected in13.1%-33% of pregnant women

3 separate studies indicate that perinatal women have an average suicide rate of 2% to 7.9%

For comparison, According to the National Institute of Mental Health, average suicide rates among women were 4.1% in 2001, and 6.1% in 2017, both lower than the higher end of perinatal suicide rates.

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Suicide terminology

Self-harm

- Suspected or confirmed- is defined as the intentional, direct injuring of body tissue, done without the intent to take one’s own life.

Suicide Plan

- Intentional harm of one’s self with the what, when, where, and how.

Suicide Attempt

- A self-injurious act with some intent to die. ( there does not have to be injury or harm, just the potential for injury or harm)

Suicide Attempt Interrupted

- Someone or something stops them during the attempt to end their life

Suicide Attempt Aborted

- Takes steps towards making suicide attempt, but them stops themselves from completing the act

Suicide Behavior

- Span of activities related to behaviors and thoughts of suicidal thinking, attempts, and completions.

Suicidal Ideation

- Thinking and having thoughts of engaging in suicidal behavior

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Discussing suicide

Acceptable Terminology No Longer Acceptable Terminology

Died of suicide Committed suicide

Suicide death/Suicided Successful attempt/suicide

Suicide attempt/Attempt to end his/her life Unsuccessful attempt/suicide

Person living with suicidal thoughts or behavior Suicide ideator or attempter

Suicide/Ended his/her life Completed suicide

Expresses suicidal ideation Manipulative, cry for help, or suicidal gesture

Working with Dealing with suicidal crisis

Non-fatal attempt at suicide Failed attempt at suicide

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Suicide rates in the United States are on the rise, especially in women.

Hypotheses Include:

In 2004, the FDA issued a black box warning for antidepressants which has resulted in a decrease in the use of antidepressants in adolescents.

Earlier onset of puberty may increase risk for depression, which is a risk factor for suicide.

Suicide rates tend to increase during times of economic downturn.

Lower marriage rates and higher divorce rates may contribute to social isolation, dissolution of family, and poverty, factors which increase risk for suicide.

Increased use of social media and cyberbullying

.

Suicide Rates Increasing in Women, Adolescent Girls

Suicide Rates Increasing in Women, Adolescent Girls. (2016, July 13)

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DID YOU KNOW?

Women in their childbearing years account for the largest group of Americans with depression

Postpartum depression is the most common complication of childbirth

There are more new cases of mothers suffering from maternal depression each year than women diagnosed with breast cancer

Despite the prevalence, maternal depression goes largely undiagnosed and untreated

Smith, D. G. (2018, August 15). An Entirely New Type of Antidepressant Targets Postpartum Depression.

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Recognizing Perinatal women at risk for suicide ideation

Risk Factors

History of Abuse

Cultural/social influences

Socioeconomic status

Demographic factors

Comorbid psychiatric conditions

Mnemonic: IS PATH WARM?

I IdeationS Substance AbuseP PurposelessnessA AnxietyT

TrappedH HopelessnessW WithdrawalA AngerR

RecklessnessM Mood Change

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Baby Blues:

70%-80% of mothers experience baby blues. Usually starts within the first couple of days after delivery, peak around one week, and taper off by the second week postpartum. Symptoms include low mood, tearful, detached, overwhelmed, etc.

Postpartum Depression:

May starts off as baby blues, but lasts longer and becomes worse with time. The symptoms are more severe with insomnia or hypersomnia, decreased appetite, increased tearfulness, lack of energy and motivation, and may have an inability to care for the newborn. Suicidal thoughts may be present, thoughts of harming the infant are rare, but can occur. 10%-20% of mothers experience PPD

*Depression can also occur during pre-conception, antepartum, intrapartum*

Baby Blues and Postpartum Depression

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What causes postpartum depression?

Baby Blues and Postpartum Depression’s actual cause is still unknown.

Thought to be caused by both biological and psychological factors.

One of the physical changes is a dramatic drop in the hormone levels of estrogen and progesterone, along with other chemical changes in the brain

Other hormones changes may occur with the thyroid gland.

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Decreases in estrogen and progesterone

Overwhelmed feeling of the responsibility

Feeling fearful or panicky

Sleep deprivation

A constant sense of worry or dread

Trouble sitting still

Dizziness or nausea

Postpartum Anxiety and Postpartum Panic Disorder

Very nervous and is recurrentShortness of breath

Chest pain

ClaustrophobiaDizziness

Heart palpitations

Numbness and tingling in the extremities

Go in waves

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Postpartum Post Traumatic Stress disorder

(PTSD)

9% of women experience postpartum post-traumatic stress disorder (PTSD) following childbirth.

Traumas could include

Prolapsed cord

Unplanned C-section

Use of vacuum extractor or forceps to deliver the baby

Baby going to NICU

Feelings of powerlessness, poor communication and/or lack of support Women who have experienced a previous trauma, are at a higher risk for experiencing postpartum PTSD.Women who have experienced a severe physical complication or injury related to pregnancy or childbirth, such as severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, perineal trauma (3rd or 4th degree tear), or cardiac disease.SYMPTOMS

Intrusive re-experiencing of a past traumatic event (which in this case may have been the childbirth itself)Flashbacks or nightmares

Avoidance of stimuli associated with the event, including thoughts, feelings, people, places and details of the eventPersistent increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response)

Anxiety and panic attacks

Feeling a sense of unreality and detachment

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Bipolar mood disorder

Bipolar I Mood Disorder

Periods of severely depressed mood and irritability

Extremely elevated mood

Rapid speech

Little need for sleep

Racing thoughts, trouble concentrating

Continuous high energyOverconfidenceDelusions (often grandiose, but including paranoid)Impulsiveness, poor judgment, distractibilityIn the most severe cases, delusions and hallucinationsBipolar II Mood DisorderPeriods of severe depression

Periods when mood much better than normalRapid speech

Little need for sleepRacing thoughts, trouble concentratingAnxiety

Irritability

Continuous high energy

Overconfidence

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Risks among perinatal women with bipolar disorder

Pregnant and postpartum women with bipolar disorder more frequently have significant mental health and early mothering challenges than other perinatal women undergoing psychiatric treatment.

The findings indicate the importance of properly identifying the disorder and developing specific treatments for women during and after pregnancy.

Brown University. (2014, February 24). Higher risks among perinatal women with bipolar disorder. ScienceDaily.

Retrieved August 21, 2019 from www.sciencedaily.com/releases/2014/02/140224124206.htm

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Borderline Personality Disorder (BPD)

Signs and Symptoms

Unstable and extreme emotions (sadness, irritability, anxiety)

Efforts to avoid being abandoned

A history of intense and unstable relationships with people

Not having a clear sense of identity

Impulsiveness (e.g. spending lots of money, sex, substance abuse, reckless driving, binge eating)

Increase in self-harm and/or suicidal behaviors

Ongoing feelings of emptinessFeelings of anger that may be intense, inappropriate or difficult to controlBeing paranoid or feeling disconnected from the world when under stressBorderline Personality Disorder (BPD) is a condition characterized by difficulties regulating emotion.

Mother's with BPDMay struggle with their relationship with their baby

May not feel the way they think that they should feel about the babyMay also find caring for the baby difficult i.e. crying baby

Can cause problems with emotional connections and relationships with baby

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You do not have to be diagnosed with OCD to experience these common symptoms of perinatal anxiety. It is estimated that as many as 3-5% of new mothers and some new fathers will experience these symptoms.

Obsessions, also called intrusive thoughts, which are persistent, repetitive thoughts or mental images related to the baby.

Occurs “out of the blue”

Compulsions, where the mom may repeat behaviors/actions often to reduce her fears and obsessions. For example: clean/reclean, checking/rechecking lights & locks, counting/recounting objects.

A sense of horror about the obsessions, upsetting to mother

Fear of being left alone with the infant

Hypervigilance in protecting the infant

Moms with postpartum OCD know that their thoughts are bizarre and are very unlikely to ever act on them.

Postpartum Obsessive Compulsive Disorder (OCD)

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0.1 - 0.2% of births

Break from Reality

Delusions or strange beliefs

Hallucinations (seeing or hearing things that aren’t there)

Feeling very irritated

HyperactivityDecreased need for or inability to sleepParanoia and suspiciousnessRapid mood swingsDifficulty communicating at timesDelusions and Beliefs make sense to her, very real and often religiousImmediate treatment for a woman going through psychosis is imperativePostpartum Psychosis

(2019, June 14). Andrea Yates Fast Facts

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postpartum OCD and postpartum Psychosis

Postpartum OCD

Thoughts are ego-dystonic

Disturbed or distraught by thoughts, “Am I going crazy?” Intrusive or obsessive thoughts

Repetitive or excessive behavior (excessive washing, checking on baby)

Avoid objects or being with baby, but wants to keep the baby safe, fear of baby being harmed

Low risk of harm to baby

Often misdiagnosed as psychosisPostpartum PsychosisThoughts are ego-syntonic Rarely distressed by thoughts

Do not have avoidant behaviorsExperience hallucinations/delusions/illogical or irrational thoughts

Periods of delirium or maniaNot common disorderHigh risk for baby

Out of touch with reality

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schizophrenia

Chronic, severely debilitating psychiatric disorder that affects ~1% of the population worldwide.

Diagnosed between the ages of 15 and 30.

Hallucinations, delusions and paranoid thoughts also avolition, anhedonia, and cognitive deficits, such as poor function, attention, and impaired working memory.

Rat studies show that maternal stress in pregnancy increases the risk for onset of schizophrenia.

Higher rate of unplanned and unwanted pregnancies

Increased risks during pregnancy include preterm deliveries, lower mean birth weight, increased incidence of intrauterine growth retardation (IUGR), premature death, and increased possibility of a psychotic breakdown during pregnancy or the post-partum period.

“

Women with previously diagnosed schizophrenia or bipolar disorder have up to a 50% chance of becoming psychotic after delivery. These women need to be closely monitored after delivery and if their medication was stopped during the pregnancy, it needs to be restarted immediately.” Dr. Lucy Puryear

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Perinatal suicide studies

The U.S. Study

2% were pregnant at the time of suicide and 3% were within 1

st

year postpartum.

Pregnancy and Postpartum is associated with a high rate of mental health disorders, including depression (13%-20%) and anxiety (10%-20%).

30% of pregnant women with depression experience SI and 20% of postpartum death is through suicide making it the 2

nd most commonly cause of postpartum death.

More than half of the women who died by suicide had mental disorders. The most common being mood disorders (95%), anxiety disorders, (9%) and schizophrenia (5%).

It suggested that perinatal women exhibited similar risk factors to non-perinatal women, which would aid in screening factors.

32% of perinatal women had a prior history of suicide attempt and 28% had known substance or alcohol abuse at the time of death.

Hispanic women were more likely to die by suicide while pregnant (10% of suicides among pregnant women) or within 1 year of pregnancy (9% of postpartum suicides)

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Perinatal suicide studies

The Canadian Study

The largest number of suicides in the perinatal period were in the last trimester of pregnancy and, especially in the last quarter of the first year postpartum.

The perinatal suicide rate was 2.58 per 100,000 live births.

Fewer than half the women who died by suicide did not receive any mental health services 30 days before their death, even though they did see their OB providers.

Perinatal women used more lethal means of suicide vs non-perinatal women. (i.e. hanging, jumping, vs overdose)

Most women who died by suicide had mental illness, not just psychotic disorders, but mood or anxiety disorders.

Lower socioeconomics and more rural locations resulted in high death by suicide rates due to lack of mental health services.

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Perinatal suicide studies

The Denmark Study

Postpartum psychiatric mothers had a 70% increased risk of suicide during the first year after delivery.

History of mental illness played a significant role in the number of perinatal suicides. 20% with baby blues and postpartum depression, and 0.1% with postpartum psychosis.

Decreased education level, immigration status, and low socioeconomics were noted to have higher death by suicide rates.

A history of self harm or previous suicide attempt, and substance abuse was a strong factor in the increased rate of perinatal suicide.

Stillbirth was not significantly associated with perinatal suicide.

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This story is shared in memory of Alexis Joy D’Achille.

Baby Adriana was born on August 30, 2013

“It was literally watching somebody you love just completely fall apart and unravel.”

Alexis had trouble breastfeeding

Would hear phantom baby cries in the night

Tearful every morning after long sleepless weeks

She was convinced her daughter was connecting with other people, but not with her

During delivery the baby had a nuchal cord which doctors think left Alexis with PTSD

She constantly worried that the traumatic birth hurt the baby and she swore she saw signs of this

When they went to see a physician he told Steven D’Achille “she’s too pretty to kill herself”

5 weeks after giving birth Alexis was 10 pounds lighter than her pre-pregnancy weight

Went to seven different hospitals and facilities in her last 13 days

“It was literally watching somebody you love just completely fall apart and unravel.”

2 month wait to see a psychiatrist

6 weeks after Alexis delivered she took her own life

All pictures - Holohan, M. (2019, May 15). Wife's death compels dad to help other moms with postpartum disorders.

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Steven D’Achille started The Alexis Joy D’Achille Foundation for Postpartum Depression. “One thing I’ve definitely learned was that mental health does not discriminate. It doesn’t care who you are. It could be anyone. It could be any woman”.

https://youtu.be/deSxZAQ_I8M

“This is the last picture ever taken of Alexis with our daughter Adriana. The following morning Alexis took her life. #MyWishForMoms is that no mom feels like Alexis did. #MyWishForMoms is that every mom gets to watch their babies grow up. #MyWishForMoms is that no mom feels like their loved ones are better off without them here and that no mom feels they are a burden”.

Steven D’Achille

All pictures - Holohan, M. (2019, May 15). Wife's death compels dad to help other moms with postpartum disorders.

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Mental health Screening for perinatal women

ACOG recommends depression screening for all women at least once during the perinatal period

Majority of childbearing women with depression are neither identified nor treated.

Stigma associated with mental illness deters women from accessing care

There is a shortage of both mental health care professionals and perinatal specialists.

Limited financial and personal

Screening for mental health should be routine

Screening tools used at TCH The Women’s Place are the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ9)

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Interpreting the EPDS, EPDS3, PHQ9, and Pittsburgh sleep quality index (PSQI)

EPDS-

Maximum score of 30

< than 8 depression not likely

9-11 depression possible

12-13 fairly high possibility of depression

14 or higher probable depression……

at TCH 10 or greater is a positive screen and

needs further evaluation for depression Always review #10 as it covers suicidal ideationEPDS-3-This focuses on 3 main questions in the EPDS, #3, #4, #5 which comprises the subscale of

anxiety in the EPDS

PHQ9-Maximun score 27 0-4 minimal depression 5-9 mild depression

10-14 moderate depression

15-19 moderately severe depression

20-27 severe depression

Always review #9 as it cover suicidal ideation

The Pittsburgh Sleep Quality Index (PSQI)-

Maximum score is 21 (the higher to score the worse the sleep quality)

Each question has a scale of 0-3

0-very good sleep

1-Fairly good sleep

2-Fairly bad

3-Very bad

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Safe-t

S

uicide

a

ssessment

f

ive

s

tep evaluation and triageStep 1 Identify Risk FactorsStep 2 Identify Protective FactorsStep 3 Conduct Suicide InquiryStep 4 Determine RiskStep 5 Document Risk

In patient consult

SWAT team

911- MAT

713-970-7520 - MCOT

Methodist ED

Crisis Clinics

Welfare check

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Treatment and Care for perinatal suicidal patients

Education

Multidisciplinary Team

Psychotherapy

Psychodynamic therapy

Cognitive behavioral therapy (CBT

)

Group therapy

Social workersHerbal supplementsBright light therapyCombination therapyMedication managementAntidepressants

BenzodiazepinesAntipsychotic

Mood StabilizersSleep Aids

*Many of these medications especially the antidepressants can take up to 5-6 weeks to become therapeutic, they need to be tapered up, then when discontinued they need to be tapered down. Stopping these medications “cold turkey” can cause withdrawal symptoms and can worsen depression*

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RESOURCES FOR SUICIDE IDEATION

National Suicide Prevention HOTLINE 1-800-273-8255

Crisis Intervention of Houston HOTLINE: 832-416-1177

Texas Children’s The Women’s Place 832-826-5281

Methodist Hospital ED, Texas Medical Center

Texas/Postpartum Support International 1-800-944-4773

The Center for Postpartum Family Health 713-561-3884

The Harris Center for Mental Health and Intellectual Development Disabilities (IDD)

NeuroPsychiatric Center 713-970-7070Legacy Community Health Services 713-830-3000Ben Taub Community Behavioral Health Program 713-643-3691/713-526-4243

Postpartum Depression HOTLINE 1-800-PPD-MOMSPsychology Today-Pregnancy, Prenatal, Postpartum Therapist in Houston -https://www.psychologytoday.com/us/therapists/pregnancy-prenatal-postpartum/tx/houston

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Conclusion

Overall, available evidence indicates that perinatal women, especially pregnant/postpartum women are more likely than the general population to endorse suicidal ideation. Recognizing women who are at risk is key, by assessing their neurobiological, psychosocial, and psychopathological risk factors. Implementing rigorous and multidisciplinary approaches through screening programs will identify women at high risk of suicidal behaviors and providing resources such as medication management, therapy, availability, and community awareness. By removing the stigma and accepting the women who have mental illnesses, and also letting these women know that they can get help, we can all give them a fighting chance.

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