The authors report no financial relationships relevant to this article.
There’s a full moon tonight—and you’re the obstetrician on call. Not that you should expect any more funny business than usual. Despite stories of werewolves and other deviants coming out of the woodwork, there is no “full moon effect”—at least not one that can be documented. Nevertheless, chances are good that you will encounter at least one of the following psychiatric challenges as you end your day in the clinic and move on to an extended vigil:
- postpartum depression
- leaving against medical advice
- antenatal illicit drug use
- denial or concealment of pregnancy.
In this article, we describe the management of these challenges and make recommendations to help increase your comfort level with patients who exhibit psychiatric problems. In some situations, our suggestions may help you manage the problem without a psychiatric consult.
CASE 1: Is it just the blues?
It is the end of your day in the clinic, and your last patient is a 30-year-old G3P3 who is 6 weeks postpartum. She describes repeated tearful episodes over the course of several weeks, decreased concentration, and poor appetite. She feels guilty because she is tired all the time and not bonding with her baby. She denies having suicidal or homicidal thoughts, or any hallucinations. She had expected her energy to return to normal over the first few postpartum weeks, but it has not. She is worried because she will soon be returning to work as a medical resident.
Does this patient have postpartum depression? Or is it another condition with overlapping symptoms?
If a mother tells you that she is suicidal or having thoughts of harming her child or others, she should be sent immediately to the nearest emergency department for psychiatric evaluation. Short of such a dramatic situation, how do you know when you should manage a patient’s depression on your own and when she should see a psychiatrist? Thorough assessment is the key.
Don’t mistake transient feelings for depression
Transient feelings of sadness, bereavement, and grief are not the same as depression, which must last 2 weeks or longer to confirm the diagnosis.
A quick mnemonic for symptoms of depression is SIG: E CAPS (as if writing a prescription for energy capsules) (TABLE 1).1 This mnemonic helps remind you to assess the patient’s sleep, interest, guilt, energy, concentration, appetite, and psychomotor function, as well as identify any suicidal ideation.
It is important to assess a woman’s sleep and appetite in addition to mood. However, differences may be difficult to ascertain due to normal changes in the postpartum period. One useful question is whether the mother is able to sleep when the baby sleeps. If she isn’t, this wakefulness may be a symptom of depression.
The Edinburgh Postnatal Depression Scale is an easy, 10-question screening tool that is completed by the patient; it can be used both during pregnancy and postpartum. It is available on the Web at a number of sites, including www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.
SIG: E CAPS—a mnemonic to assess for depression1
|Decreased (sometimes increased) Sleep|
|Feelings of Guilt|
|Decreased (sometimes increased) Appetite|
|Psychomotor retardation, slowness|
|Suicidal thoughts, plans, or intent|
Besides postpartum depression, the differential diagnosis for altered mood in the postpartum period includes several entities.
Baby blues generally occurs quite soon after birth and resolves within 2 weeks. It involves crying, emotional lability, and irritability.2 It occurs in around 50% to 75% of new mothers (compared with postpartum depression, which affects 10% to 20%).3-5
Postpartum psychosis often involves the onset of psychotic symptoms within 1 week after delivery. The patient may exhibit both mood symptoms and psychosis. For example, she may believe that the baby is not hers or hear voices commanding her to kill the baby or warning her not to trust her healthcare providers.6 Postpartum psychosis has a prevalence of about 0.2%.3-6
This psychosis can be organic in nature or can arise from a preexisting mood disorder or schizophrenia. Because treatment varies, depending on the cause, a thorough medical workup is needed.