Postpartum Depression

1
Postpartum Depression

• April Wilson MD
• PGY1 OB/Gyn Rotation
• Family and Social Medicine

2
Case

• DP is a 19yo G1P1 female who presented to
  clinic with her newborn for a newborn visit and
  f/u visit for herself. DP has a healthy 1 wk old
  baby girl. DP is no longer in a relationship
  with the FOB. DP recently went to ED due to
  perineal pain. Today DP has no complaints.

3
DP

• PMH Strabismus, Congenital deformity of Left
  hand, Depression (suicidal ideation) at age 14
• Social Hx Lives with mom(recovering drug
  addict) and baby, dropped out of high school
  during pregnancy, at home school lessons about 2x
  week, plans to start job corp in the Spring, no
  cigs, no ETOH, no drugs not currently sexually
  active
• When asked about feeling down, DP admitted to
  having moments of feeling depressed due to her
  circumstances but tries not to dwell on such
  feelings. She remains hopeful for her future and
  looks forward to the job corp program.

4
What is postpartum depression?

• Postpartum depression a major depressive
  episode that is temporally associated with
  childbirth
• Postpartum blues baby blues, heightened
  emotions, peaks in 3-5 days after delivery, may
  last up until 14 days
• (tearfulness, anxiety, irritability, fatigue,
  mood lability)
• Postpartum psychosis severe postpartum
  depression associated with delusions

5
Who is most likely to be affected?

• Estimated that 10-20 of mothers have postpartum
  depression
• Postpartum blues occurs in about 50-80 of
  mothers
• 2/3 women have onset within 6 weeks of delivery
• African-American and Hispanic mothers more likely
  than Caucasian mothers to have early symptoms

6
Causes of Postpartum Depression

• Possibly related to hormonal changes
• ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ??????

7
Risk Factors

• Underlying psychiatric disorder
• Lack of social support
• Anxiety and depression during pregnancy
• Hx of depression
• Moms with preterm infants(lt32 wks)

• baby blues
• Stressful life events
• Hx of postpartum depression
• Bipolar (risk for postpartum psychosis)
• Catastrophizing labor pain

Multiparity and breastfeeding associated with
reduced risk no association b/w C-sec and
postpartum depression
8
Factors that may delay or prevent women from
seeking help

• Being a first-time mom
• Pressures of society to be a good mom
• Fear of being sent to jail or baby being taken
  away if disclose thoughts to PCP
• Confusion about which doctor to see about their
  concerns

Also, remember that physicians my delay
detection by minimizing a womans distress in an
effort to be reassuring.
9
Making the diagnosis-usually presents up to 4-6
months postpartum

• Symptoms depressed mood, lack of pleasure or
  interest, sleep disturbance, weight loss, loss of
  energy, agitation, feelings of worthlessness or
  inappropriate guilt, diminished concentration,
  thoughts of death or suicide
• Social Hx depressed mood during pregnancy, life
  stress, postpartum anxiety, poor marital
  adjustment, infant sleep problems
• Physical poor eye contact, tearfulness, blunt
  affect, inattention to personal appearance
• Diagnosis DSM-IV criteria for major depression
  SIGECAPS
• symptoms which may be considered normal
  experiences after childbirth

10
Diagnosis Continued.

• Screening Edinburgh Scale
• Tests CBC, TFTs
• Rule Out postpartum blues, postpartum
  psychosis, anemia, postpartum thyroid dysfunction
• NOTE Postpartum Psychosis (hallucinations or
  delusions, manic) is a MEDICAL EMERGENCY!!!!
  Patient must be hospitalized immediately.
• -usually presents within first two weeks,
  incidence rate is 0.1-0.2 percent

11
Screening Edinburgh Scale

• AAFP recommends universal screening at 6-wk
  postpartum visit
• A score higher than 12 is 100 sensitive and
  95.5 specific in detecting major depression
• One study showed that postpartum women residing
  in the inner city had a prevalence rate of 22
  when screened with EPDS

12
Edinburgh Scale
In the past 7 days
1. I have been able to laugh and see the funny
side of things
6. Things have been getting on top of me
As much as I always could
Yes, most of the time I havent been able
Not quite so much now
to cope at all
Definitely not so much now
Yes, sometimes I havent been coping as well
Not at all
as usual
No, most of the time I have copied quite well
2. I have looked forward with enjoyment to things

No, I have been coping as well as ever
As much as I ever did
Rather less than I used to
7 I have been so unhappy that I have had
difficulty sleeping
Definitely less than I used to
Yes, most of the time
Hardly at all
Yes, sometimes
Not very often
3. I have blamed myself unnecessarily when
things
1
No, not at all
went wrong
Yes, most of the time
8 I have felt sad or miserable
Yes, some of the time
Yes, most of the time
Not very often
Yes, quite often
No, never
Not very often
No, not at all
4. I have been anxious or worried for no good
reason
No, not at all
9 I have been so unhappy that I have been crying

Hardly ever
Yes, most of the time
Yes, sometimes
Yes, quite often
Yes, very often
Only occasionally
No, never
5 I have felt scared or panicky for no very good
reason
Yes, quite a lot
10 The thought of harming myself has occurred to
me
1 
Yes, sometimes
Yes, quite often
No, not much
Sometimes
No, not at all
Hardly ever
Never
Administered/Reviewed by _________________________
_______ Date ______________________________
Response categories are scored 0,1,2,3 to
increased severity. Items marked with are
reversed scored 3,2,1,0. Total score is adding
all scores. Scores above 12 likely have
depression
13
Complications of Postpartum Depression

• May affect the mothers ability to care for the
  infant
• Disturbs the bond b/w mother and infant
• Increases the childs and entire familys risk of
  psychiatric disorders
• Higher incidence of SIDS in children of mothers
  with postpartum depression

14
Treatment

• Prognosis- may last 6-12 months women at risk
  for postpartum depression and depression in the
  future
• Professional and/or social support
• Counseling
• Antidepressants
• Transdermal estrogen

15
Counseling

• Psychosocial and psychological interventions may
  reduce depressive symptoms (ex. Group therapy)
• Interpersonal psychotherapy-focuses on patients
  interpersonal relationships and changing roles
• Multi-component intervention associated with
  improved short-term improvements for low-income
  women
• Partner participation

16
Antidepressants

• Fluoxetine only drug proven as effective as
  cognitive-behavioral counseling and more
  effective than placebo transmits through breast
  milk
• Nortriptyline
• Sertraline
• Fluvoxamine
• ---may have to use for 9-12 months, data lacking
  in regards to optimal duration

17
Hormonal Therapy

• Transdermal estrogen effective in severe
  postpartum depression
• - women treated for 6 months
• - estrogen patch more effective than placebo
  for treating postpartum depression, effect
  occurred by 1st month and remained statistically
  significant
• - for last 3 months, women given
  progesterone 12days/month to reduce risks of
  unopposed estrogen
• Sublingual 17-beta estradiol
• - effective in 2 case reports and
  uncontrolled series of 23 cases

18
Alternative options

• Enhanced professional and social support
• Massage therapy (reduced anxiety)
• Behavioral sleep intervention
• Electroconvulsive therapy

19
Prevention

• Group psychotherapy may reduce risk of depression
  for up to 3 months postpartum
• Insufficient evidence regarding prophylactic
  antidepressants postpartum
• Music therapy may reduce prenatal stress,
  anxiety, and postpartum depression

20
Educational Materials for Patients

• Postpartum Support International
• Helpline 1-800-944-4PPD
• Website http//postpartum.net
• NEW YORK STATE CO-COORDINATOR LAUREN SAFRAN,
  LCSW WESTCHESTER, THE BRONX, THE HUDSON VALLEY,
  QUEENS and LONG ISLAND
• Telephone [phone]

21
Plan for DP

• Risk Factors hx of depression, lack of social
  support
• Post-partum visit plan physical exam, Edinburgh
  scale, further discuss support system, f/u in
  regards to topics discussed at visit with social
  worker

22
References

• Blenning, Carol and Paladine, Heather. An
  Approach to the Postpartum Office Visit.
  American Family Physician 2005 72 2491-6,
  2497-8)
• Dennis, C-L Hodnett, E Cindy-Lee. Psychosocial
  and psychological interventions for treating
  postpartum depression (Cochrane Review). In
  The Cochrane Library 2008 Issue 2. Chichester,
  UK John Wiley and Sons, Ltd.
• Epperson, CN. Postpartum Major Depression
  Detection and Treatment. American Family
  Physician 1999 April 15, 1999.
• Ferber SG, Granot M, Zimmer EZ. Catastrophizing
  labor pain compromises later maternity
  adjustments. Am J Obstet Gynecol 2005 192
  826-31.
• Hoffbrand S, Howard L, Crawley H. Antidepressant
  treatment for post-natal depression. Cochrane
  Database Syst Rev. 2001(2)CD002018.
• Miller L. Postpartum depression. JAMA 2002
  287 762-5.
• Morris-Rush JK, Freda MC, Bernstein PS.
  Screening for postpartum depression in an
  inner-city population. Am J Obstet Gynecol 2003
  188 1217-9.
• Adolescence 1996 Winter 31(124) 903
• Am J Obstet Gynecol 2005 Feb 192(2) 522
• Am J Psychiatry 2006 Aug 163(8) 1435, 1443
• Arch Womens Ment Health 2007 10(6) 259)
• Arch Womens Ment Health 2006 Sep 9(5) 273
• BMJ 2002 May 4 324(7345) 1062
• Can J Psychiatry 2000 Aug 45(6) 554
• Cochrane Library 2007 Issue 4 CD006116
• Early Hum Dev 2003 Aug 73(1-2) 61
• Lancet 1996 Apr 6 347(9006) 930
• Lancet 1998 Jan 10 351(9096 109
• Lancet 2007 Nov 10 370(9599) 1629