Based on the latest data by the Centers for Disease Control and Prevention (CDC), approximately 1 in 36 (~2.7%) children in the United States are diagnosed with autism spectrum disorder (ASD).1 Over the last few years, the increase in clinical ASD diagnoses has led some researchers to attribute this rise to mis- and overdiagnoses of the condition,2 and also, to the growing awareness among the general population and scientific community.3
We reached out to clinicians involved in the diagnosis and care of patients with ASD to get further insights on screening for and diagnosing autism in the US and the collaborative efforts that may result in more favorable patient outcomes.
The discussion panel included the following clinicians:
Pediatric neurologist Ann Neumeyer, MD, medical director of the Massachusetts General Hospital’s Lurie Center for Autism in Lexington and associate professor of neurology at Harvard Medical School in Boston.
Nora D. Friedman, MD, child, adolescent, and adult psychiatrist at Lurie Center for Autism and instructor at Harvard Medical School.
Clinical neuropsychologist Susanne W. Duvall, PhD, ABPP, associate professor of pediatrics and psychiatry, division of psychology, and associate director of clinical training, Clinical Psychology PhD Program, Institute on Development and Disability at Oregon Health & Science University (OHSU).
Ann Neumeyer, MD
Nora D. Friedman, MD
Susanne W. Duvall, PhD, ABPP
In 2013, the American Psychiatric Association (APA) developed standardized criteria —according to the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) — to diagnose ASD by combining 4 conditions: autism, Asperger syndrome, childhood disintegrative disorder, and pervasive development disorder not otherwise specified (PDD-NOS).4
Are Diagnostic Criteria for ASD Misleading?
However, in a review, neuropsychologist David Rowland wrote that autism is more of a brain anomaly than a developmental disorder and that the National Institutes of Health (NIH)’s list of signs and symptoms may be too vague to confirm autism.5
Following the revision of the criteria that introduced the concept of a “spectrum,” the diagnosis of autism appears to be based on behaviors shared with other diagnoses of uncertain similarities.3,6 The broad definition of autism and overlapping symptoms with complex conditions have created challenging situations in practice, with false diagnoses — both false positives and negatives — affecting autism assessment.5,7
Based on these scenarios, we asked Drs Neumeyer and Friedman about diagnosing autism in clinical practice.
Q: What are some of the typical and atypical signs of autism that you have come across? What are your clinical pearls in identifying these signs and symptoms? How quickly must they be addressed?
Dr Neumeyer: The young children with language delay are often diagnosed early and the children who don’t have language delay often have delayed diagnosis or misdiagnosis. When I think about diagnosing autism, I think about the DSM-5 criteriafor autism4 that the child has to have: social communication delays, delays in social and emotional reciprocity, nonverbal communication, and maintaining relationships. Many children with autism who are considered “intelligent” have impaired relationships; however, unless you ask parents, they don’t tell you that.
With regard to health outcomes, one of the other things that is really important is that autism in many individuals is associated with sensory function, and patients become really picky about the foods that they eat, which can lead to nutritional deficiencies. Some patients with these nutritional deficiencies have poor bone growth and density, which can lead to osteoporosis.
Dr Friedman: ASD can be defined as deficits in social communication and interaction, as well as restricted and repetitive behaviors. We want to understand how these issues manifest across settings. As part of the diagnostic work-up, it is important to assess for co-occurring conditions, such as anxiety or attention-deficit/hyperactivity disorder (ADHD). We try to think holistically about the individual with ASD, talking with families about therapeutic and behavioral interventions, school and employment supports, and medication management if indicated. In addition, we aim to connect patients with services as quickly as we can.
Diagnosing Autism in Adulthood
Age at ASD diagnosis is directly related to achieving optimal outcomes, which may be improvements in cognition and language or adaptive behavior, as well as reduced costs for families, society, and the health care system as a whole.8 In recent years, studies have shown an increase in autism assessments among adults, including diagnoses in both adulthood and after the childhood-to-adulthood transition.9
In a 2023 study published in the International Journal of Mental Health Systems,8 the lived experience of patients with an ASD diagnosis in adulthood was noted. Some of the common themes in their ASD diagnostic journeys were observing differences and similarities between themselves and patients with ASD; barriers in diagnosis, such as cost of care and wait times; and emotional health.
Drs Neumeyer and Duvall presented fairly similar views on why autism diagnoses happen later in life, and the outcomes associated with them.
Q: Data from studies have indicated an increase in autism being diagnosed in adulthood, which can lead to poor health outcomes.8 Can you explain the reasons for these diagnostic delays, and how providers can address this?
Dr Neumeyer: Adults who are being diagnosed with autism are typically considered “intelligent” and who have been able to mask their symptoms or that their condition was misdiagnosed, for example, with anxiety, ADHD, or learning disabilities. There is a smaller group of older adults who are not diagnosed early because when they were younger, autism was just defined as very severe repetitive behaviors and lack of language skills.
Dr Duvall: The most common scenario is that individuals with more nuanced symptoms of autism can be missed in childhood and then go on to receive a diagnosis in adulthood, but in retrospect, the same behavior patterns or social communication [delays] were always present. Autism has a genetic component, thus sometimes, when we provide an ASD diagnosis to a child, the parent notes that they were “just like them” when they were a child and may go on to seek evaluation for an ASD diagnosis themselves.
Gaps and Barriers in Autism Evaluation
To identify barriers in receiving autism diagnosis, researchers at Stanford University, California, conducted a study that revealed sparse and uneven distribution of diagnostic resources in the US, which resulted in increased waitlists and travel distance. Specifically, patients from rural communities were less likely to be diagnosed than those from urban communities who lived closer to diagnostic centers, indicating a gap in access to care.10
In addition to this, the important role of pediatric primary care providers — the first point of care during early childhood — in helping access autism services has also been noted in a 2022 study published in Autism Research.11
Dr Neumeyer spoke further about the existence of barriers in the diagnosis of ASD.
Q: In the US, several clinical specialties are facing a shortage of pediatricians due to certain factors — increasing demand, lesser students opting for pediatrics as their specialty, and poor financial incentives — resulting in gaps in access to autism resources.10 Can you describe some of the most common barriers in achieving a timely and accurate autism diagnosis?
Dr Neumeyer: The number of individuals opting for the subspecialty of developmental behavioral pediatrics is very low, with many fellowships not being able to fill their slots.One of the results of that isthat it is the specialty that diagnoses and cares for children with neurodevelopmental disabilitiesand autism. So, we are in desperate need of more developmental behavioral pediatricians.
Every state in the US has different rules according to which it is decided who diagnoses autism; in Massachusetts, any MD or psychologist can make a diagnosis. One of the barriers in Massachusetts is that most pediatricians don’t feel comfortable or have the training to make a diagnosis. The way their practices are run, it is very difficult to make an autism diagnosis because they see patients quickly, and diagnoses require more time spent with patients. So, typically, psychologists, pediatric neurologists, and psychiatrists make a diagnosis in Massachusetts.
The other, more research-based, challenge is the lack of a biomarker for autism, so we can’t diagnose just with a test. There are some online companies that have been good at getting a validated diagnosis for autism, but those are new.
What’s Needed for Autism Diagnosis? Role of Collaboration Between Specialists
Experts agree that a multidisciplinary team of health care professionals and awareness of “red flags” by parents, families, and teachers can be an optimal diagnostic approach.8
Q: What is the role of each neurologist, psychiatrist, and psychologist in diagnosing autism? In addition, what collaborative efforts must be taken by the specialties to screen for and diagnose autism, and how should providers go about referrals for autism?
Dr Neumeyer: Generally, here, we start with a psychologist for evaluation of autism and the neurologist and psychiatrist work hand-in-hand, especially when there are atypical features or physical findings. It is very important to bring in the neurologist to make sure there’s no genetic involvement or other syndrome causing or associated with the autism. The psychiatrist can be very important when there are behavioral difficulties. The reality is that there are not enough child psychiatrists in the US, and so, many pediatric neurologists and pediatricians also treat the behavioral aspect of children with autism.
Dr Friedman:Ideally, patients undergo a multipronged evaluation. This can include [evaluation of] history, a clinical interview, observation, physical exam and work-up, and cognitive and/or developmental testing. Understanding a patient’s unique profile informs treatment planning. The available resources in a given area will, in part, dictate the specific clinicians whom a family sees, the subsequent referrals that are made, and access to services. Collaboration among team members is essential for optimal care for patients and their families.
Dr Duvall: In our interdisciplinary ASD-specific assessment clinic, 100% of the individuals coming in report that social difficulties are, at least, part of why they presented with this diagnostic question. However, only about 30% to 50% of the older children and teens who present for a comprehensive ASD assessment receive an ASD diagnosis, while rates in children younger than age 4 may be closer to 60% to 80%.
There is high variability across primary care providers and pediatricians around expertise in neurodevelopmental disorders. If caregivers are concerned, they should talk with their primary care provider to complete in office screening, such as questionnaires or behavioral observation, and then ask for a referral to a specialist for evaluation, as early interventions are often the most effective in supporting skill development.
"
["post_title"]=>
string(77) "Who Diagnoses Autism? Expert Views From Neurology, Psychiatry, and Psychology"
["post_excerpt"]=>
string(157) "In a discussion panel, a pediatric neurologist, a psychiatrist, and a clinical neuropsychologist share their insights on screening for and diagnosing autism."
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(74) "who-diagnoses-autism-expert-views-from-neurology-psychiatry-and-psychology"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-26 09:37:05"
["post_modified_gmt"]=>
string(19) "2024-04-26 13:37:05"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(43) "https://www.psychiatryadvisor.com/?p=130935"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[1]=>
object(WP_Post)#4807 (24) {
["ID"]=>
int(130632)
["post_author"]=>
string(5) "45510"
["post_date"]=>
string(19) "2024-04-22 11:30:00"
["post_date_gmt"]=>
string(19) "2024-04-22 15:30:00"
["post_content"]=>
string(10857) "
Autism spectrum disorder (ASD) is a complex developmental disorder involving persistent deficits in social communication and interaction in addition to restricted, repetitive behaviors, interests, and activities.1,2 The American Psychiatric’s Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) provides the criteria for ASD diagnosis based on specific symptom profiles.1 As part of these criteria, the DSM-5-TR outlines specifiers of symptom severity, which it categorizes as “levels.”1 This article describes the criteria and various levels of symptom severity used in the diagnosis of ASD.
Changes to the Autism Diagnosis
Autism was first identified as a distinct diagnosis in DSM-III, which was published in 1980.3 In DSM-IV-TR, a patient with symptoms of autism would likely be diagnosed with 1 of 4 disorders under the category of pervasive developmental disorder (PDD): autistic disorder, Asperger’s disorder, childhood disintegrative disorder, or PDD not otherwise specified.4 However, because researchers determined that these 4 diagnoses were not consistently applied by different clinicians, PDD was replaced with autism spectrum disorder (ASD) in DSM-5.4 A patient who met the criteria for 1 of the 4 PDD diagnosis in DSM-IV-TR will likely meet the criteria for ASD in DSM-5.4
DSM-5-TR Criteria for Autism Spectrum Disorder
The DSM-5-TR criteria for ASD are summarized as follows1:
A. Persistent deficits in social communication and social interaction as manifested by all of the following:
Deficiencies in social-emotional reciprocity (examples: inability to engage in normal back-and-forth conversation, reduced sharing of interests/emotions/affect, failure to initiate or respond to social interactions);
Deficiencies in nonverbal gestures used in social interaction (examples: problems with eye contact, body language, or understanding/using gestures, lack of facial expressions and nonverbal communication); and
Deficiencies in developing, maintaining, and understanding relationships (examples: lack of interest in peers, difficulty making friends).
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following:
Repetitive motor movements, use of objects, or speech (examples: body rocking, arm or hand flapping, lining up toys, repeating words just spoken by another person);
Insistence on sameness, inflexible adherence to routine, or ritualized patterns of behavior (examples: difficulty with transitions, rigid thinking patterns, needing to eat the same food each day);
Highly restricted, fixated interests that are abnormal in intensity or focus (examples: a strong attachment to peculiar objects); and
Hypersensitivity or hyporeactivity to sensory input or abnormal interest in sensory aspects of the environment (examples: indifference to pain or temperature, adverse response to specific sounds or textures).
C. Symptoms must be present in the early developmental period.
D. Symptoms significantly impair social, occupational, or other important functional areas.
E. Deficits are not better explained by intellectual disability or global developmental delay.
Specifiers for the ASD diagnosis include the following1:
With or without accompanying intellectual impairment;
With or without accompanying language impairment;
Associated with a known medical or genetic condition or environmental factor;
Associated with another neurodevelopmental, mental, or behavioral disorder;
With catatonia, and
The current severity specifiers.
The 3 Levels of Autism Spectrum Disorder
The current severity specifiers consist of 3 levels, ranging from least severe (Level 1) to most severe (Level 3). The severity of each of the 2 main criterion — social communication and restricted, repetitive behaviors — should be rated separately.1
Level 1: Requires Support
Individuals with ASD categorized as Level 1 have the least severe symptoms and require the lowest level of support.
Social communication:Patients classified as Level 1 will have noticeable impairments unless supports are in place. They generally have difficulty initiating social interactions and will give atypical responses to others' social overtures. Patients classified as Level 1 may have a reduced interest in social interactions. For example, a person specified as Level 1 might be able to speak full sentences and communicate, but would not be able to have a mutual, back-and-forth conversation. Additionally, their efforts to make friends often fail.1
Restricted, repetitive behaviors: These individuals' rigid behavior limits their ability to function in 1 or more contexts. They tend to have challenges alternating between activities, and their independence is hindered by issues with organization and planning.1
Level 2: “Requires Substantial Support”
Patients with ASD classified as Level 2 have more severe symptoms that cause greater impairment and require substantial support.1
Social communication:Patients specified as Level 2 have marked deficits in verbal and nonverbal social communication skills. Even with support, their social impairments are apparent. They generally have limited ability to initiate social interactions, and will provide decreased or aberrant responses to others' social overtures. For example, a patient classified as Level 2 might be able to speak basic sentences, but their interactions with others would be limited to narrow special interests, and their nonverbal communication would be odd.1
Restricted, repetitive behaviors: Individuals with ASD Level 2 have inflexible behavior, problems adjusting to change, or similar behaviors that are frequent enough to be obvious and interfere with functioning in various contexts. They also have distress and/or difficulty changing focus or action.1
Level 3: “Requires Very Substantial Support”
Patients with ASD specified as Level 3 have the most severe symptoms and require very substantial support.1
Social communication:Individuals classified as Level 3 have extreme deficits in verbal and nonverbal social communication that cause severe impairments in functioning. Their ability to initiate social interactions is very limited, and they will provide minimal response to others' social overtures. They tend to only respond to very direct social approaches. For example, a patient specified as Level 3 would have very few words of intelligible speech and would rarely initiate interactions with others.1
Restricted, repetitive behaviors: Patients with Level 3 exhibit inflexible behaviors, problems adjust to change, or similar behaviors that interfere with every aspect of their lives. They experience tremendous distress and difficulty changing focus or action.1
How the Levels Are Used
Using the levels to clarify the severity of ASD symptoms gives clinicians and caregivers information they can use to tailor services and support specific to an individual patient's needs. However, it is important to recognize that these levels are only used to describe the patient's current symptomatology.1Symptoms of ASD might fluctuate over time; can vary greatly based on the patient's developmental level, age, environment, and other characteristics; and might fall below Level 1.1
Whilehelpful, the levels should not be used to determine a patient's eligibility for specific services or treatments; that requires an individualized assessment that takes into account the patient's personal priorities and goals.1
"
["post_title"]=>
string(32) "Levels of Autism: An Explanation"
["post_excerpt"]=>
string(334) "The American Psychiatric’s Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) provides the criteria for ASD diagnosis based on specific symptom profiles. As part of these criteria, the DSM-5-TR outlines specifiers of symptom severity, which it categorizes as “levels.”"
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(16) "levels-of-autism"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-23 14:07:34"
["post_modified_gmt"]=>
string(19) "2024-04-23 18:07:34"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(43) "https://www.psychiatryadvisor.com/?p=130632"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[2]=>
object(WP_Post)#4800 (24) {
["ID"]=>
int(130605)
["post_author"]=>
string(5) "45524"
["post_date"]=>
string(19) "2024-04-19 09:55:54"
["post_date_gmt"]=>
string(19) "2024-04-19 13:55:54"
["post_content"]=>
string(11860) "
People with autism spectrum disorder (ASD) face numerous healthcare disparities relative to their peers without ASD, as individuals with ASD often have reduced access to high-quality health care and experience lower satisfaction with patient-provider communication.1 Recent studies have begun to shed light on the unique obstetric challenges that people with ASD may experience during the perinatal period, although research on the intersectional experience of autism and pregnancy remains limited to date.2,3
“This population of childbearing people are unique in that they face multiple challenges such as unmet healthcare needs, communication issues, and experience more barriers to receiving appropriate education,” said Patricia D. Suplee PhD, RNC-OB, FAAN, associate professor at Rutgers University School of Nursing in Camden, New Jersey.4,5
Unique Challenges of Autism and Pregnancy
Along with the physical, emotional, and service-related challenges that are associated with pregnancy more generally, people with ASD often experience additional perinatal difficulties compared to neurotypical individuals, according to Megan Freeth, MSc, PhD, professor of neurodevelopmental psychology and director of research and innovation in the Department of Psychology at the University of Sheffield in the United Kingdom.
In a 2023 survey-based study published in the Journal of Autism and Developmental Disorders, Hampton et al compared the perinatal experiences of 384 individuals with ASD and 492 individuals without ASD. They found that those with ASD reported lower satisfaction with health care during perinatal medical encounters and were more likely to feel overwhelmed by the sensory aspects of childbirth.6
"
Experts point to the need for ongoing provider education and research to further understand and improve care obstetric care for individuals with ASD.
Although providers should avoid making assumptions about a patient’s sensory experience, Prof Freeth explained that many people with ASD can experience intense challenges with the sensory aspects of pregnancy.7 For example, they may have an extremely heightened sense of smell and taste, sensitivity to touch, or sensitivity to the lights and sounds of clinical environments.
“For some, sensory experiences during birthing can result in feeling so overwhelmed that a disconnect from reality can be experienced,” she said. “Autistic people tend not to express emotional reactions in the same way as non-autistic people, and during birthing this can lead to clinical staff not realizing the severity of stress levels and can also exacerbate miscommunication, resulting in the autistic person not understanding their options and not having their preferences understood” by clinicians.
Studies have also indicated that communication challenges could make it harder for individuals with ASD to ask providers for help during labor and the postpartum period.3 “Some autistic individuals may be unsure how to answer open-ended questions or convey how they are feeling during labor,” said Jane Donovan, PhD, RNC-MNN, assistant clinical professor at Drexel University College of Nursing and Health Professions in Philadelphia, Pennsylvania. “Additionally, during childbirth, there are numerous encounters with healthcare professionals and staff who have varying levels of experience and knowledge working with neurodiverse individuals, and these social encounters with unfamiliar people can be stressful for an autistic individual.” She noted that the stress and pain of labor can exacerbate communication differences for autistic individuals.
Studies have also shown that individuals with ASD are more likely to experience postnatal depression and anxiety relative to their peers without ASD.8,9
Improving Obstetric Care and Outcomes in ASD
In providing obstetric care to patients with ASD, Dr Donovan emphasized that providers need to recognize the vast diversity within this population. “It is essential to understand that autism is a spectrum condition with a great deal of variation among autistic individuals, and a provider’s view of autism should not be based on 1 patient,” she remarked.
Dr Suplee offered the following recommendations for providers developing a care plan for autism and pregnancy:
Assess each birthing person as an individual and do not assume that all patients with ASD will communicate or react the same way
Do not make assumptions about how to provide intrapartum or postpartum care based on perceived client social interactions
Learn how to interpret social cues and sensory overload and how to make appropriate accommodations to best meet the client's needs10
Provide effective communication and tailor all education specifically to the client
Discuss support services that can be incorporated during each phase of the client's birthing journey
Educate staff on what it means when a person experiences a heightened sensory perception of sound, light, or touch and what types of interventions can be utilized in these instances
Prof Freeth noted, “Consistent support from the same team members throughout pregnancy is particularly valued by autistic people.” In addition, “Having clear, precise information provided in written form to supplement information provided via discussions tends to be helpful as some autistic people take a little longer than non-autistic people to process information and appreciate being able to go over key information again in their own time,” she explained.
Other helpful adjustments may include options for individual or online classes or support groups — rather than large group-based formats — and allowing the presence of a patient advocate at appointments.9
Clinicians may need to take extra time to listen to the special concerns of these patients, especially regarding sensory issues. Providers and hospitals may also consider making small adjustments to the sensory environment, such as not having music playing or screens on in a waiting room, having the option to wait for appointments in a non-crowded space, or using a lamp for lighting instead of overhead lights, Prof Freeth recommended.
Dr Donovan added that having sensory kits that contain items such as noise-canceling headphones, stress balls, sunglasses, and fidget toys available on obstetric units may help to ease sensory overload. “Implementing strategies to create a sensory-friendly environment in waiting rooms, examination areas, and on the labor and postpartum units can provide a more welcoming environment to neurodiverse individuals,” she stated.
Given the high rates of comorbid mental health disorders among individuals with ASD,6 Dr Donovan advised that mental health screenings should be included in the plan of care for autism and pregnancy.
Unmet Needs
Experts point to the need for ongoing provider education and research to further understand and improve obstetric care for individuals with ASD. Ideally, such efforts would include “autistic-led training and co-production of service development whereby autistic people are involved in designing maternity services,” Prof Freeth suggested. She noted the need for research focused on the development and evaluation of such services, along with studies that would elucidate the lived experiences of pregnancy, birthing, and the postpartum period among people with ASD.
Dr Donovan said she would like to see provider training programs focused on “interventions to facilitate communication and create sensory-friendly environments.”
“Policies and protocols should be developed and used as guides when caring for birthing people with ASD during the intrapartum and postpartum periods,” Dr Suplee recommended. She cited the need for research exploring strategies for teaching new mothers with ASD about parenting skills and recognizing infant cues, as well as qualitative studies to “build evidence on how best to care for this population during the antepartum, intrapartum, and postpartum periods that will lead to improved maternal health outcomes.”
"
["post_title"]=>
string(71) "Autism and Pregnancy: Improving Obstetric Care for Patients with Autism"
["post_excerpt"]=>
string(158) "Psychiatry Advisor spoke with obstetric and psychiatric experts on how best to support pregnant individuals with autism throughout their perinatal experience."
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(35) "autism-and-pregnancy-obstetric-care"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-19 15:59:57"
["post_modified_gmt"]=>
string(19) "2024-04-19 19:59:57"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(43) "https://www.psychiatryadvisor.com/?p=130605"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[3]=>
object(WP_Post)#4795 (24) {
["ID"]=>
int(130334)
["post_author"]=>
string(5) "45524"
["post_date"]=>
string(19) "2024-04-12 09:25:54"
["post_date_gmt"]=>
string(19) "2024-04-12 13:25:54"
["post_content"]=>
string(16443) "
Our easy-to-read fact sheets provide clinicians with reliable information to share with patients and their caregivers.
Postpartum depression is defined as the onset of major depression associated with childbirth that negatively affects the mood and behavior of the parent.1 During pregnancy, an individual undergoes considerable hormonal fluctuations, including increased levels of estrogen and progesterone. After childbirth, these hormone levels drop rapidly, which can contribute to the onset of postpartum depression. Additionally, the postpartum period is often accompanied by increased stress due to the demands of caring for a newborn, sleep deprivation, and hormonal changes.
For new parents battling postpartum depression, finding the right medication to manage your condition can be a critical step towards healing and supporting your mental health. Our helpful guide aims to inform patients about the risks, benefits, and considerations associated with postpartum depression medication as they begin their recovery.
"
For new parents battling postpartum depression, finding the right medication to manage your condition can be a critical step towards healing and supporting your mental health.
Major Depressive Disorder
Depression is a general term for a common psychiatric disorder that presents with symptoms such as sadness, irritability, loss of interest in activities, feelings of worthlessness, hopelessness, guilt or anxiety, concerns over death, and/or suicidal ideation. Individuals with depression may also experience fatigue, difficulty concentrating, and changes in their appetite weight, and sleep.2
Major depressive disorder, or MDD, is characterized by a sad mood and/or lack of interest in activities. A diagnosis of MDD requires the presence of at least 5 of the key symptoms for most of the day, nearly every day, or for at least 2 weeks.1,3
Postpartum Depression
Postpartum depression is classified as a major depressive disorder that begins during or after childbirth, typically within the first 3 months and up to 1 year after childbirth. Approximately 15% to 20% of childbearing individuals develop postpartum depression each year. Although it is one of the most common complications of the postpartum period, it is often underdiagnosed and undertreated.1,4
Symptoms of postpartum depression may overlap with MDD, but include unstable mood, anxiety, irritability, extreme sadness, decreased pleasure, low energy, as well as obsessive worry – typically about the baby’s health, feeding, and safety. More serious symptoms that require immediate evaluation by a provider are thoughts about self-harm, suicide, or harming one’s child.1,3,4
While the exact cause of postpartum depression is not fully understood, several key factors contribute to its development:5,6
Hormonal Changes: Hormonal fluctuations during and after pregnancy can impact neurotransmitter levels in the brain, which play crucial roles in regulating mood
Genetic Predisposition: Individuals who have a family history of depression or mood disorders are at higher risk for postpartum depression
Psychological Factors: Psychological factors, such as a history of depression or anxiety, can increase the risk of developing postpartum depression. Additionally, stressors related to childbirth, such as difficult labor, pregnancy complications, or concerns about parenting, can contribute to the onset of depression
Social Support and Stress: Lack of social support, relationship difficulties, financial strain, and other stressors can exacerbate the risk for postpartum depression
Physical Health: Vitamin D deficiency, gestational diabetes, obesity, chronic health conditions, sleep disturbances, or health complications during pregnancy or childbirth can also contribute to the development of PPD
Medication Options
If you are experiencing symptoms of postpartum depression, speak with your provider to discuss treatment options. Currently, antidepressants in combination with psychotherapy are recommended to treat moderate-to-severe depression.1 Commonly used postpartum depression medication options include the following:
Nortriptyline is a TCA that inhibits reuptake of norepinephrine and serotonin into the neurons to increase their levels, as well as inhibit the activity of other agents.
Mirtazapine is an atypical antidepressant that works as an antagonist at central presynaptic a2-adrenergic receptors to enhance noradrenergic and serotonergic activity.
Sleepiness or drowsiness Increased appetite Weight gain Dizziness
Brexanolone and zuranolone are medications approved for treatment of postpartum depression. They work on the GABAA receptors to regulate mood and behavior.
Sleepiness or drowsiness Dry mouth Passing out Flushing of the skin or face Dizziness Fatigue Diarrhea Common cold Urinary tract infection
It's important to recognize that postpartum depression is a complex and multifaceted condition that varies from person to person. Although the transition to parenthood can be challenging for many individuals, when symptoms persist and significantly impact daily functioning, it may indicate the presence of postpartum depression. Seeking professional help is crucial for diagnosis and treatment.
Frequently Asked Questions
How can I tell if I’m experiencing postpartum depression?
If you think you may have postpartum depression, it is important to speak with your provider. Your provider can provide a clinical assessment or utilize self-report tools, such as the Edinburgh Postnatal Depression Scale (EPDS) – a widely and reliably used screening tool for postpartum depression.15 Physicians are encouraged to screen for postpartum depression at the first postnatal obstetrical visit. If you or a loved one are experiencing symptoms of postpartum depression, follow-up with your provider to discuss diagnostic and treatment options.
Are these medications safe for me to take while breastfeeding?
It is recommended that patients who are currently breastfeeding, or planning on breastfeeding, should first speak with their provider to discuss the potential risks and benefits of different medication options. The decision to use antidepressants during postpartum while breastfeeding involves careful consideration of both the potential risks and benefits for both the parent and the baby.
Treating postpartum depression with antidepressants can improve parental mental health and reduces the risk for paternal self-harm or harm to their child. However, some medications can pass into breast milk.10-13 There is ongoing research regarding the long-term effects of antidepressant exposure during breastfeeding on infant development. While some studies have suggested potential concerns, the overall consensus is that the benefits of breastfeeding typically outweigh the potential risks for antidepressant exposure.
For example, sertraline and paroxetine have a better safety profile for infants during breastfeeding, but there is less available data for other serotonin reuptake inhibitors such as escitalopram and duloxetine.1,8 When taking fluoxetine, it is recommended to monitor infants for agitation, irritability, poor feeding, and poor weight gain.16 Research also indicates that zuranolone has potential risk for harm to the infant. It is recommended to use effective contraception during zuranolone treatment and for 1 week after the final dose.14
In many cases, the benefits of treating postpartum depression with antidepressants outweigh the potential risks, but it's important to carefully consider all factors and explore alternative treatments if appropriate.
When should I stop taking my medication?
It is important to consult your provider before discontinuing treatment. Discontinuation during pregnancy may increase your likelihood of a depression relapse, compared with individuals who continue antidepressants.11,12 However, if you experience new or worsening depression, anxiety, irritability, insomnia, mania, or suicidal thoughts and behavior, you should speak with your provider to determine if this is a side effect of your medication.
Newer postpartum depression medications such as Brexanolone and Zuranolone have specific durations of therapy. Zuranolone should only be taken once daily for 14 days while brexanolone is administered as a continuous infusion over 60 hours (2.5 days).13,14
You should stop taking your medication and seek immediate medical help if you experience a seizure or an allergic reaction such as development of skin rash, hives, chest pain, edema, and shortness of breath.
