Title: Postpartum Depression
1Postpartum Depression
- April Wilson MD
- PGY1 OB/Gyn Rotation
- Family and Social Medicine
2Case
- 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.
3DP
- 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.
4What 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
5Who 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
6Causes of Postpartum Depression
- Possibly related to hormonal changes
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7Risk 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
8Factors 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.
9Making 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
10Diagnosis 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 -
11Screening 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
12Edinburgh 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
13Complications 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
14Treatment
- 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
15Counseling
- 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
16Antidepressants
- 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
17Hormonal 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
18Alternative options
- Enhanced professional and social support
- Massage therapy (reduced anxiety)
- Behavioral sleep intervention
- Electroconvulsive therapy
19Prevention
- 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
20Educational 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 917.658.0624
21Plan 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
22References
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Approach to the Postpartum Office Visit.
American Family Physician 2005 72 2491-6,
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and psychological interventions for treating
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The Cochrane Library 2008 Issue 2. Chichester,
UK John Wiley and Sons, Ltd. - Epperson, CN. Postpartum Major Depression
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