XXXX香港理工大學(xué)冬季培訓(xùn)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

Malformations.Behavioralteratogenicity.Drugeffectsonthenewborn-toxicity,withdrawal.Bloodvolumechanges:Druglevelsshiftintothesub-therapeuticrangeduringpregnancyortoxicrangepostpartum.Pote議ntia縮慧lRi安sks彎ofNot展Trea薪tingWith倒Psy促chia爪tric齊Med狀icat輪ionsDep暢res孝sio崗n,兔oth垃er增unt摸rea夾ted驚ps度ych茶iat符ric扭di堅(jiān)sor宿der扔sd別uri睜ng搞pre梳gna酒ncy辮ar像ea科sso怕cia得ted刑wi賠th肚poo控ro憐bst慮etr海ic重out樓com細(xì)es.Inu民tero閣str蓋ess志reta撈rds武feta筋lgr掘owth舍,ma缸ydi獄srup黃tno幕rmal廢beh許avio揀ral歸deve亞lopm得ent.Chil憤dren去of依m(xù)ent燈ally凳ill所mot挎hers刑hav亭emo拒rem防edic抬al,煙psyc膠holo那gica擠l,a隨ndc固ogni軌tive點(diǎn)pro憲blem錄s.Inc腦rea財(cái)sed凈ri節(jié)sk派of高rec付urr棍enc毅ea堂nd賢tre含atm爽ent抓re階sis筒tan據(jù)ce謝of服ill尾nes絕s.Anti漢depr癢essa哀nts渣in續(xù)Preg細(xì)nanc應(yīng)yan顏dLa澆ctat房誠(chéng)ionSSR期Is炮rel籠ati境vel均ys愿afe裁ev拐en邀dur潛ing劃1sttrim葡este弟rex怕cept食par預(yù)oxet米ine交(inc射reas惕esb覽irth掙def蒸ect方rate睡s).皂Worr甘isom劣ere對(duì)cent阿rep垮orts苦tha公tex借posu肝red肆urin濁gla廊tep頓regn爺ancy陳mor愚eth圣and慕oubl返esp訪reva駛lenc恨eof才pul錢mona甜ryh巴yper砍tens側(cè)ion獄inn宣ewbo輸rns.SSR殺Is塵(es浙pec耐ial遠(yuǎn)ly黨ser癥tra酒lin呈e,察cit尖alo底pra脾m,挑par蜘oxe捆tin步e)殿and氏TC娃As電(es處pec畝ial尼ly陜nor勉tri被pty橋lin沃e)欺rel專ati晝vel湖ys濃afe質(zhì)in皺br臣eas懶t-f昂eed鴉ing徹.F糞luo外xet宅ine戶ac君cum證ula使tio借n,爪TCA筑-in司duc殼ed舉sei椒zur活es.丸Ve誰(shuí)nla禮fax粒ine茅ac銷cum姨ula勾tes籌in褲mi半lk.蕩In饞suf罪fic隆ien臣ti掀nfo胖rma超tio說(shuō)na嘆bou鉛tn才ewe推ra壯nti蓬dep車res束san遙ts,次tr揮azo命don唱e.Bupr發(fā)opio稼n:F辨DAr頓isk抱cate漲gory筑B.MAOI妄sas訂soci利ated絮wit卡hgr鍛owth椅ret榴arda雄tion劫,co蘇ngen術(shù)ital產(chǎn)mal蛾form光atio切ns.Moo伯dS歇tab去ili翅zer徐si里nP湖reg叢nan體cy忌and餡La膀cta疑tio岡nLith尸ium:紫Fir幟stt換rime德ster勁exp姥osur咱e-0.安1%r沸isk絹ofE灑bste破in’s抱ano寺maly芬(10助-20在xRR喚).S膽afer六2ndand委3rdtrim擁este直rs.I玻ncr哈eas委es經(jīng)bir著th勵(lì)wei咐ght陰.N需ewb堅(jiān)orn連hy阻pot鍬oni已cit鞋y,期arr假hyt患hmi腦as,游hy研pot姜hyr做oid嘉ism恥,D唱I.誤Con桿tra見ind我ica西ted臟du猾rin鏟gn吐urs氏ing厘.Ant撲ico轎nvu謠lsa高nts濟(jì):F聾irs腔tt收rim帖est膊er據(jù)exp粱osu葛re-口hig聾her煌ra乏tes朱of背mi坊sca倘rri或age五,b魯irt梯hd敞efe鑄cts富(N匪TD,理or霧ofa炭cia盯lc撿lef廣ts)積,I甘UGR退,n芒eon這ate竭to熟xic沿ity疾,c叨ogn容iti畫ve窩imp扯air雨men泡tw辱ith佛VL驕P&池CB故Z(類VLP識(shí)>勉CBZ禿)b綠ut鵲not確wi銜th裙LTG木(s耕mal旗ler敞da固tab矩ase查).催Som障ee中vid行enc稅eo夠xca規(guī)rba趙zep友ine趣sa文fer裙th渴an謠VLP磁.N附urs辜ing涂-ve鞏ry造low寬VL均P,呀CBZ堤br丟eas驗(yàn)tm抵ilk畜co皺nce飼ntr殖ati刮ons逃.L耕TG?Anx漏iol頑yti璃cs謀Dur列ing層Pr傍egn社anc猾y/L三act再ati翁onDiaz秒epam龍,ot顫her熄benz孔o(hù)s:i星nit捕ial曲re督por狡ts影tha邊t1sttrim吩este潑rex蠶posu盯ret獄odi川azep觀am,鍋othe川rbe姑nzos堆inc乘reas捎eri家sko姥for飄alc景l(fā)eft繳sno飯tsu腥bsta銳ntia曉ted.Clo對(duì)naz低epa羨m:lo熟west巴te涂rato附geni獲city晃of任all拘benz灑osi封nan蘿imal糊stu腹dies長(zhǎng).No伙cle幼art轟erat猶ogen鉗icit影ywh達(dá)enu區(qū)sed揀inp許regn厘ant新epil堂epti陪cs.Lora盜zepa飾m:sa良fet悶rack龍rec冤ord.逮Lim用ited堪mil襖kpe戴netr插atio呈n.L摩ow-m忘ediu詠mdo甩ses宮cons非ider綿edr盟easo伶nabl腦ysa饒fe.Ris溜ks:in載fant疼sed賄atio傲n,h掀ypot刃onic獲ity,紀(jì)pos扯tnat城alw舅ithd飲rawa停l.Alpr墓azol好am:s賭ome暑ev踩ide助nce皺th撓at歡exp躲osu李re哀may泊in雖cre漿ase躁or功al美cle翁ft桂ris恭k1韻2t走ime棉s(男0.0慰6%鏈to按0.7石%).Busp呢iron己e:?Anti父psyc宵hoti童csi潔nPr總egna耍ncy/掙Lact細(xì)atio傻nPhe店not慈hia蠅zin劉es饅1st穴tr等ime哈ste把re脆xpo懸sur畝em括ay筑inc惜rea建se梅mal憐for遲mat紀(jì)ion湯ra賞te礦fro折m2子.0%衰to滲2.罵4%.懲Al切iph圾ati釘c>另pi濤per梢azi凡ne,訪pi車per地idi燃ne.秒Ha柳lop掌eri乎dol栗re斤lat勞ive晴ly輸saf耽e.Inf夕ant友to繭xic暗ity扯:E頂PS,融bo昏wel料ob型str嗽u(píng)ct蹈ion棗(r好are亭).Aty焦pic翻als雅:m凳alf演orm芝ati尿on,線IU泰GR伸rat戒es帳app溝ear學(xué)WN廉Ls.愿Me練tab晝oli勒c,民neu設(shè)rod內(nèi)eve悔lop膀men條tal迅ef陵fec鎮(zhèn)ts,田ne劉ona犁te廊tox火ici棉ty,倦br偷eas辜tm樂(lè)ilk右co啞nce清ntr劑ati宗ons璃un燃kno溝wn.EPS蕩trea緣瑞tmen色ts:貴Diph劇enhy舌dram萬(wàn)ine屋isp辱roba漸bly洞safe源sta桑ltho聚ugh安birt寇hde棍fect吹sra癢tes若omew絡(luò)hat喝high半erw挑ith成1st中trim默este廉rex撒posu之re;俱incr另ease恭dma交lfor戀mati撫onr島ate盈with占ben撓ztro貪pine途,tr遇ihex肯yphe廚nidy糞l,a痛nde棄spec否iall山y(tǒng)am抱anta虧dine脊.Pr省opra漆nolo縣lis挨rea傾sona閘bly材safe博.Psy伏c(diǎn)ho初tro慎pic搬si死nP毯reg棟nan銜cy/繞Lac倡tat晨ion裁:G壁ene椅ral壯Co鍬nsi國(guó)der墳ati敢onsExpl摔ain朽risk芹san釋dbe脅nefi徹tso單fme霜dica脆tion捷and脊non則-med獸icat嗽ion腫trea掏tmen擊tap疊proa超ches勒,re甘spec浪tth增emo閃ther顏’sw瞞ishe味s,d啄ocum伍ent溫deci膽sion丑-mak聞ing.Don爹’t偶use性me可dic愛ati是on限unl嫩ess拳tr配uly榜ne桐ces題sar景y,閉esp估eci殘all腫yd驢uri押ng現(xiàn)the避fi崗rst躁tr免ime科ste珍r.Dos逃em晌edi簽cat午ion擁st重oa器deq韻uat辰ely續(xù)tr恭eat像di狠sor顏der監(jiān)s(貿(mào)i.e碎.,霞don銹’t楊und琴er-騰med屋ica挖te絹to嚴(yán)dec查rea形se津dru陪ge提xpo完sur壞e).Psyc唱hotr好opic垂sin交Pre碰gnan證cy/L抓acta膽tion挖:Ge末nera洞lCo薦nsid捆erat免ions耗-con紋t.Adju凝std違oses拐of虛some兆med灣icat婦ions選(mo痰ods鴨tabi皆lize聯(lián)rs,確anti于depr榆essa墓nts)窩to飲comp寫ensa瞧tef否orc即hang芝esi巖nbl販ood秧volu侄mea葡spr諒egna崖ncy磨adva邁nces巖and匠pos姓tpar秋tum.Cons拾ider弓tap膛erin歪gdo效seo石rst盤oppi場(chǎng)ngs孫ome詞medi給cati熄ons救pre-蹲part織umt濱odi跳mini宴shd疑rug鑰effe棗cts豪ont倉(cāng)hen扭ewbo初rn,暮espe申cial億lyi似fth丘ere糕are基obst充etri牲c(diǎn)co催mpli蔥cati臨ons.Guid滔elin違esf委orT屈reat炮ment杰of阻Majo碑rDe纖pres善sion脾Dur胸ing斧Preg工nanc既y/La隙ctat探ionSSR球Is搖(fl止uox輛eti后ne,及se盯rtr厭ali畜ne)殼or礎(chǔ)se宏con昌dar宅ya沙min勇et嘗ric杏ycl陸ic暫ant美ide餐pre暫ssa管nts赤(d翼esi純pra笛min斤e,炎nor權(quán)tri汽pty憂lin鈔e)要dur蓋ing茅pr遇egn團(tuán)anc西yo奸rl相act映ati它on.撤Bu麗pro受pri就on鏡is堵pro章bab搜ly答rea餅son筍abl漫ys閣afe豆.Moni欠tor彈TCA斷bloo憶dle搬vels附;in羅crea祝sed怕ose素asn駱eces虛sary負(fù)as半preg辯nanc淘yad拖vanc爽es,徐cut映back其dos下eat灑par跑turi未tion若.Guid慰elin臣esf制orT來(lái)reat紐奉ment渡of茶Mani造aDu寸ring碑Pre棍gnan蠶cy/L闊acta性tionFir勵(lì)st陪tri味mes帆ter牢:H每alo背per過(guò)ido憐lf墊or銀psy騰cho爭(zhēng)sis覽,c清lon器aze還pam浪fo海ra蹈git過(guò)ati艷on;蹤蝶if探mo任od具sta洋bil商ize供ri托sn對(duì)ece姿ssa倦ry,藏li什thi況um先may升be辟fi掉rst栽ch迷oic深e.汽ECT膀.Seco刻nd/T咳hird穴tri慨mest爬er/P房誠(chéng)ostp紛artu亂m:L延ithi和umo料ran羞tico醒nvul潑sant就s,h送alop姐erid滔ola漲nd/o短rcl懷onaz柳epam凍if泛trul灰yne抄eded難.Co納ntin群uet郊reat陽(yáng)ment憐pos澇tpar撇tum認(rèn)ifn旅oob笑stet粗ric硬comp獸lica的tion列s.F葉ollo踢wbr是east腸-fed搞inf梁ants亡clo跳sely勵(lì).Gui柜del延ine脊sf育or蠢Tre繩atm郵ent稻of陰Ma頌nia山Du罵rin鍛gP序reg經(jīng)nan特cy/付Lac損tat齡ion菊-co賭ntMon嘆ito賠rb跪loo禁dl跡eve痕ls讓of慕moo釋ds膝tab希ili梨zer矩sa陷sp糠reg婆nan種cy價(jià)adv醉anc老es工and提in蹲cre善ase汽do仙ses抵to拋ma趨int米ain假ef臘fec貼tiv婦ec列onc昨ent葉rat爬ion還s.Atp完artu猜riti妻on,瓦decr炭ease唯dos辯eso章fmo盡ods緣瑞tabi珠lize鍬rsb屯yap第prox翻imat畢ely公one奶thir撕dto檢pre新vent頭lev請(qǐng)els撿from歲ris載ing供into愚the剃tox料icr隊(duì)ange數(shù).Gui致del構(gòu)ine嫩sf辜o(jì)r桂Tre肥atm劈燕ent榮of拴An壞xie閱ty旬Dis桌ord季ers搭Du孟rin憂gP奇reg舞nan煙cy/聽Lac遵tat遞ionPan展ic妥Dis析ord肺er:則SS革RIs婚or霞se棚con升dar描ya寧min棵eT遇CAs絨.C儀lon舒aze煌pam站if堪a恐ben盛zod責(zé)iaz愁epi臥ne哄is粉nec案ess眾ary坐.Obs安ess掉ive高-Co店mpu倒lsi縮慧ve鼻Dis搶ord逮er:為SS著RIs球or探cl亂omi摸pra膚min劑ei童fS喬SRI辦sa魔re像ine樸ffe下cti險(xiǎn)ve傻(ri擔(dān)sk怎of嚷hyp犧ote倦nsi羨on耐dur亮ing雕pr討egn藝anc抽y,吵inf罪ant吊se丈izu院res錯(cuò)).Gui配del勿ine杏sf摟or斷Tre扎atm態(tài)ent勤of紗Ps縱ych獨(dú)osi件sD衰uri班ng相Pre晃gna芳ncy數(shù)/La乘cta查tio怠nHalo闖peri濱dol漿woul搞dge灑nera擠lly壩bet遷hef服irst盒ch投oice枝alt擊houg沾hph連enot翻h(huán)iaz章ines徑pro椒babl答yin父crea警ser贊isk鴨mini廳mall縣y.Fir哭st病cho憂ice舅fo軍rc貿(mào)ont戀rol繭lin槍gE仰PS筒is牛dip令hen乓hyd毒ram晶ine趟.T溜ry探to脊avo偵id稼dur章ing國(guó)fi價(jià)rst咬tr源ime娛ste翻r.Man徒agi武ng埋Pre土gna殿ncy堪in籍Wo狗men萬(wàn)Wh轎oR逼equ枕ire暢Ch堅(jiān)ron引ic嬸Psy并cho汪tro望pic勞Me丟dic具ati恢onEmph摔asiz浴eth鐮eim撐port樂(lè)ance椅of窄birt堆hco雹ntro原lan澤dpl那anni誤ngp傭regn怖anci轎es.Sto硬pm憤eds望du添rin席g1sttrim級(jí)este記r,i明ffe什asib支le.Plan炊A:鎮(zhèn)Ifp境ossi垮ble,尖tap刺era沖nds摧top惜medi米cati雄onp版rior液to狡atte痕mpts孔to翅conc般eive到,e.伙g.a肢tth跟ebe魯ginn附ing重ofa御men陶stru懲alc灣ycle慚.Pla仔nB廳:D蛇ete音ct卻pre笛gna芝ncy祖as濫ea扣rly紋as格po墊ssi抹ble漁(2即wk脫sw城ith艇OT外Cp透reg池nan桐cy噴tes被ts)敵,t舉hen蹈ta既per卵/st盆op羞