Clinical Review

In postpartum depression, early treatment is key

Author and Disclosure Information

The tragedy of Andrea Yates, the Texas mother convicted of drowning her 5 children, raises questions about the role of physicians in identifying and treating women at risk for severe postpartum depression. In most cases, Ob/Gyns are the first line of defense.


 

References

Key Points
  • Between 12% and 16% of women experience a major depressive episode in the postpartum period. Of these, approximately 30% have thoughts of suicide or infanticide/homicide.
  • Postpartum depression (PPD) often is associated with comorbid anxiety disorders.
  • Women who have had repeated episodes of depression almost always relapse when they discontinue an antidepressant during pregnancy.
  • Selective serotonin reuptake inhibitors (SSRIs) and tricyclics are used most commonly to treat PPD. When psychosis is present, antipsychotic drugs and/or electroconvulsive therapy also are options.

In the postpartum period, between 12% and 16% of women experience a major depressive episode that can have severe and long-lasting consequences for both mother and infant.1,2 If left untreated, postpartum depression (PPD) can impair maternal-infant bonding and hinder the child’s cognitive and emotional development.

This article is based on our experience caring for women with PPD, and aims to help the Ob/Gyn detect and diagnose the disorder more quickly and make psychiatric or psychotherapeutic referrals when appropriate.

Many women fail to report depressive symptoms during their routine postpartum visit.

Risk factors

Key risk factors, such as a history of PPD or depression, have been identified as predictors of PPD (Table 1).3,4 Although the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) states that the onset of PPD occurs within 4 weeks of giving birth,5 our clinical experience indicates that it can occur up to 1 year after birth. The essential feature of a major depressive disorder, according to the DSM-IV, is “a clinical course that is characterized by one or more Major Depressive Episodes” (Table 2).

PPD often is associated with comorbid anxiety disorders, which manifest in many ways. Panic attacks frequently are the first indication of existing or impending depression. A small percentage of women will experience intrusive obsessional thoughts of harming their infants.

TABLE 1

Risk factors for postpartum depression

Major factors
  • History of PPD
  • History of depression
  • Family history of depression, especially PPD
  • Depression during pregnancy
Contributing factors
  • Poor social support
  • Adverse life events
  • Marital instability
  • Younger maternal age (14 to 18 years)
  • Infants with health problems or perceived poor temperaments
  • Unwanted or unplanned pregnancy
  • Being a victim of violence or abuse
  • Low self-esteem
  • Low socioeconomic status

TABLE 2

DSM-IV criteria for a major depressive episode

  1. Five or more of the following symptoms must be present daily or almost daily for at least 2 consecutive weeks:
    1. Depressed mood*
    2. Loss of interest or pleasure*
    3. Significant increase or decrease in appetite
    4. Insomnia or hypersomnia
    5. Psychomotor agitation or retardation
    6. Fatigue or loss of energy
    7. Feelings of worthlessness or guilt
    8. Diminished concentration
    9. Recurrent thoughts of suicide or death
  2. The symptoms do not meet the criteria for other psychiatric conditions.
  3. The symptoms cause significant impairment in functioning at work, school, and social activities.
  4. The symptoms are not caused directly by a substance or general medical condition.
  5. The symptoms are not caused by bereavement after the loss of a loved one.
*At least one of the 5 symptoms must be #1 or #2. SOURCE: Adapted from Diagnostic and Statistical Manual of Mental Disorders. 4th ed [text revision]. Washington, DC: American Psychiatric Association; 2000.

Screening and diagnosis

Many women fail to report depressive symptoms to their obstetricians during the routine postpartum visit. A recent study of 391 outpatients in an obstetric practice demonstrates the value of using a screening instrument to identify possible PPD cases at this time. When the women were screened with the standardized Edinburgh Postnatal Depression Scale (EPDS), the rate of detection of PPD was 35.4%, compared with a spontaneous detection rate of 6.3%.6

The EPDS, shown on page 65, is a 10-item self-report questionnaire developed by Cox and colleagues and used specifically to detect PPD.7 A minimum score of 12 or 13 or higher warrants a diagnosis of PPD. The instrument can be used as a screening tool at 6 to 8 weeks postpartum and can be repeated over several visits to track symptoms. It has been validated, computerized, and translated into more than 12 languages and can be copied and used free of charge.

A new screening tool, the Postpartum Depression Screening Scale (PDSS), was recently developed and validated by Beck and colleagues to help clinicians identify and respond to PPD as early as possible.8 Depressive symptoms are rated on a 5-point scale, and the total score is used to determine the overall severity of depressive symptoms. Higher PDSS scores reflect more severe symptoms and indicate that the patient should be referred for psychiatric evaluation. The PDSS is published by Western Psychological Services (www.wpspublish.com).

Management guidelines

Based on our experience and the available evidence, we offer these recommendations to Ob/Gyns managing patients with PPD:

  1. During the initial postpartum assessment, use screening tools such as the EPDS or the PDSS to identify symptom patterns and assist with diagnosis.
  2. Give the patient educational materials about PPD and her treatment options to help her make informed decisions. Reading lists, appropriate research articles, lists of local resources, and Web sites can increase her awareness of PPD and drive home the importance of seeking and complying with treatment. When appropriate (e.g., in cases of moderate to severe PPD), refer the patient for counseling and encourage her to include her partner, family members, and/or other social supports.
  3. If pharmacotherapy is to be prescribed, discuss the medication’s benefits and potential risks for both mother and infant—over the short and long term—in an honest and open fashion.
  4. Outline a treatment plan with the patient and her partner. This should include 6 weeks of treatment during the acute phase, as well as maintenance and long-term therapy. During the acute phase, the mood of the patient should be carefully monitored on a weekly basis. It may be necessary to include a psychiatrist or mental healthcare worker during this phase.
  5. If applicable, discuss the planning of future pregnancies while the woman is still on pharmacotherapy—and include her partner, if at all possible. Women who have experienced repeated episodes of depression almost always relapse when they discontinue an antidepressant during pregnancy.

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