Postpartum DepressionPostpartum Depression

April Wilson MDApril Wilson MD

PGY1 OB/Gyn RotationPGY1 OB/Gyn Rotation

Family and Social MedicineFamily and Social Medicine

CaseCase

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

DPDP PMH:PMH: Strabismus, Congenital deformity of Left hand, Strabismus, Congenital deformity of Left hand,

Depression (suicidal ideation) at age 14Depression (suicidal ideation) at age 14

Social Hx:Social Hx: Lives with mom(recovering drug addict) and Lives with mom(recovering drug addict) and baby, dropped out of high school during pregnancy, at baby, dropped out of high school during pregnancy, at home school lessons about 2x week, plans to start job corp home school lessons about 2x week, plans to start job corp in the Spring, no cigs, no ETOH, no drugs; not currently in the Spring, no cigs, no ETOH, no drugs; not currently sexually activesexually active

When asked about feeling down, DP admitted to having When asked about feeling down, DP admitted to having moments of feeling depressed due to her circumstances moments of feeling depressed due to her circumstances but tries not to dwell on such feelings. She remains but tries not to dwell on such feelings. She remains hopeful for her future and looks forward to the job corp hopeful for her future and looks forward to the job corp program.program.

What is postpartum depression?What is postpartum depression? Postpartum depression: a major depressive Postpartum depression: a major depressive

episode that is temporally associated with episode that is temporally associated with childbirthchildbirth

Postpartum blues: “baby blues”, heightened Postpartum blues: “baby blues”, heightened emotions, peaks in 3-5 days after delivery, emotions, peaks in 3-5 days after delivery, may last up until 14 daysmay last up until 14 days

(tearfulness, anxiety, irritability, fatigue, mood lability)(tearfulness, anxiety, irritability, fatigue, mood lability)

Postpartum psychosis: severe postpartum Postpartum psychosis: severe postpartum depression associated with delusionsdepression associated with delusions

Who is most likely to be affected?Who is most likely to be affected? Estimated that 10-20% of mothers have Estimated that 10-20% of mothers have

postpartum depressionpostpartum depression

Postpartum blues occurs in about 50-80% of Postpartum blues occurs in about 50-80% of mothersmothers

2/3 women have onset within 6 weeks of delivery2/3 women have onset within 6 weeks of delivery

African-American and Hispanic mothers more African-American and Hispanic mothers more likely than Caucasian mothers to have early likely than Caucasian mothers to have early symptomssymptoms

Causes of Postpartum DepressionCauses of Postpartum Depression

Possibly related to hormonal changesPossibly related to hormonal changes ??????????????????????????????????????????????????????????????????????

??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????

Risk FactorsRisk Factors

Underlying psychiatric Underlying psychiatric disorderdisorder

Lack of social supportLack of social support Anxiety and Anxiety and

depression during depression during pregnancypregnancy

Hx of depressionHx of depression Moms with preterm Moms with preterm

infants(<32 wks)infants(<32 wks)

““baby blues”baby blues” Stressful life eventsStressful life events Hx of postpartum Hx of postpartum

depressiondepression Bipolar (risk for Bipolar (risk for

postpartum psychosis)postpartum psychosis) Catastrophizing labor Catastrophizing labor

painpain

*Multiparity and breastfeeding associated with reduced risk; no association b/w C-sec and postpartum depression

Factors that may delay or prevent Factors that may delay or prevent women from seeking helpwomen from seeking help

Being a first-time momBeing a first-time mom

Pressures of society to be a “good mom”Pressures of society to be a “good mom”

Fear of being sent to jail or baby being taken away Fear of being sent to jail or baby being taken away if disclose thoughts to PCPif disclose thoughts to PCP

Confusion about which doctor to see about their Confusion about which doctor to see about their concernsconcerns

**Also, remember that physicians my delay detection by minimizing a woman’s distress in an effort to be reassuring.

Making the diagnosisMaking the diagnosis-usually presents up to 4-6 months postpartum-usually presents up to 4-6 months postpartum

Symptoms:Symptoms: depressed mood, lack of pleasure or depressed mood, lack of pleasure or interest, interest, sleep disturbancesleep disturbance, , weight lossweight loss, , loss of loss of energyenergy, agitation, feelings of worthlessness or , agitation, feelings of worthlessness or inappropriate guilt, inappropriate guilt, diminished concentrationdiminished concentration, , thoughts of death or suicidethoughts of death or suicide

Social Hx:Social Hx: depressed mood during pregnancy, life depressed mood during pregnancy, life stress, postpartum anxiety, poor marital stress, postpartum anxiety, poor marital adjustment, infant sleep problemsadjustment, infant sleep problems

Physical:Physical: poor eye contact, tearfulness, blunt poor eye contact, tearfulness, blunt affect, inattention to personal appearanceaffect, inattention to personal appearance

Diagnosis:Diagnosis: DSM-IV criteria for major depression DSM-IV criteria for major depression SIGECAPSSIGECAPS

****symptoms which may be considered normal experiences after childbirthsymptoms which may be considered normal experiences after childbirth

Diagnosis Continued….Diagnosis Continued….

Screening: Edinburgh ScaleScreening: Edinburgh Scale Tests: CBC, TFTsTests: CBC, TFTs Rule Out: postpartum blues, postpartum Rule Out: postpartum blues, postpartum

psychosis, anemia, postpartum thyroid dysfunctionpsychosis, anemia, postpartum thyroid dysfunction NOTE: Postpartum Psychosis (hallucinations or NOTE: Postpartum Psychosis (hallucinations or

delusions, manic) is a MEDICAL EMERGENCY!!!! delusions, manic) is a MEDICAL EMERGENCY!!!! Patient must be hospitalized immediately.Patient must be hospitalized immediately.

-usually presents within first two weeks, incidence -usually presents within first two weeks, incidence rate is 0.1-0.2 percentrate is 0.1-0.2 percent

Screening: Edinburgh ScaleScreening: Edinburgh Scale

AAFP recommends universal screening at 6-AAFP recommends universal screening at 6-wk postpartum visitwk postpartum visit

A score higher than 12 is 100% sensitive and A score higher than 12 is 100% sensitive and 95.5% specific in detecting major 95.5% specific in detecting major

depressiondepressionOne study showed that postpartum women One study showed that postpartum women

residing in the inner city had a prevalence residing in the inner city had a prevalence rate of 22% when screened with EPDSrate of 22% when screened with EPDS

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 haven’t been able Not quite so much now to cope at allDefinitely not so much now Yes, sometimes I haven’t been coping as well

Not at all as usualNo, most of the time I have copied quite well2. 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 No, not at allwent 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 all4. 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 Yes, sometimes Yes, quite often No, not much Sometimes No, not at all Hardly ever

Never

Administered/Reviewed by ________________________________ Date ______________________________

1

1 

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

Edinburgh Scale

Complications of Postpartum Complications of Postpartum DepressionDepression

May affect the mother’s ability to care for the infantMay affect the mother’s ability to care for the infant

Disturbs the bond b/w mother and infantDisturbs the bond b/w mother and infant

Increases the child’s and entire family’s risk of Increases the child’s and entire family’s risk of psychiatric disorderspsychiatric disorders

Higher incidence of SIDS in children of mothers Higher incidence of SIDS in children of mothers with postpartum depressionwith postpartum depression

TreatmentTreatment

Prognosis- may last 6-12 months; women at risk for Prognosis- may last 6-12 months; women at risk for postpartum depression and depression in the futurepostpartum depression and depression in the future

Professional and/or social supportProfessional and/or social support

CounselingCounseling

AntidepressantsAntidepressants

Transdermal estrogenTransdermal estrogen

CounselingCounseling Psychosocial and psychological interventions may Psychosocial and psychological interventions may

reduce depressive symptoms (ex. Group therapy)reduce depressive symptoms (ex. Group therapy)

Interpersonal psychotherapy-focuses on patient’s Interpersonal psychotherapy-focuses on patient’s interpersonal relationships and changing rolesinterpersonal relationships and changing roles

Multi-component intervention associated with Multi-component intervention associated with improved short-term improvements for low-income improved short-term improvements for low-income womenwomen

Partner participationPartner participation

AntidepressantsAntidepressants

Fluoxetine: only drug proven as effective as Fluoxetine: only drug proven as effective as cognitive-behavioral counseling and more effective cognitive-behavioral counseling and more effective than placebo; transmits through breast milk than placebo; transmits through breast milk

NortriptylineNortriptyline SertralineSertraline FluvoxamineFluvoxamine

---may have to use for 9-12 months, data lacking in ---may have to use for 9-12 months, data lacking in regards to optimal durationregards to optimal duration

Hormonal TherapyHormonal Therapy

Transdermal estrogen: effective in severe Transdermal estrogen: effective in severe postpartum depressionpostpartum depression

- - women treated for 6 monthswomen treated for 6 months

- estrogen patch more effective than placebo for treating - estrogen patch more effective than placebo for treating postpartum depression, effect occurred by 1postpartum depression, effect occurred by 1stst month and month and remained statistically significantremained statistically significant

- for last 3 months, women given progesterone - for last 3 months, women given progesterone 12days/month to reduce risks of unopposed estrogen12days/month to reduce risks of unopposed estrogen

Sublingual 17-beta estradiolSublingual 17-beta estradiol - - effective in 2 case reports and uncontrolled series of effective in 2 case reports and uncontrolled series of

23 cases23 cases

Alternative optionsAlternative options

Enhanced professional and social supportEnhanced professional and social support Massage therapy (reduced anxiety)Massage therapy (reduced anxiety) Behavioral sleep interventionBehavioral sleep intervention Electroconvulsive therapyElectroconvulsive therapy

PreventionPrevention

Group psychotherapy may reduce risk of Group psychotherapy may reduce risk of depression for up to 3 months postpartumdepression for up to 3 months postpartum

Insufficient evidence regarding prophylactic Insufficient evidence regarding prophylactic antidepressants postpartumantidepressants postpartum

Music therapy may reduce prenatal stress, Music therapy may reduce prenatal stress, anxiety, and postpartum depressionanxiety, and postpartum depression

Educational Materials for PatientsEducational Materials for Patients

Postpartum Support International:Postpartum Support International:

Helpline: 1-800-944-4PPDHelpline: 1-800-944-4PPD

Website: Website: http://postpartum.nethttp://postpartum.net NEW YORK STATE CO-COORDINATOR: LAUREN SAFRAN, LCSW NEW YORK STATE CO-COORDINATOR: LAUREN SAFRAN, LCSW

WESTCHESTER, THE BRONX, THE HUDSON VALLEY, QUEENS WESTCHESTER, THE BRONX, THE HUDSON VALLEY, QUEENS and LONG ISLAND and LONG ISLAND

Telephone: 917.658.0624Telephone: 917.658.0624

Plan for DPPlan for DP

Risk Factors: hx of depression, lack of Risk Factors: hx of depression, lack of social supportsocial support

Post-partum visit plan: physical exam, Post-partum visit plan: physical exam, Edinburgh scale, further discuss support Edinburgh scale, further discuss support system, f/u in regards to topics discussed at system, f/u in regards to topics discussed at visit with social workervisit with social worker

ReferencesReferencesBlenning, Carol and Paladine, Heather. An Approach to the Postpartum Office Visit. American Family Physician 2005; 72: Blenning, Carol and Paladine, Heather. An Approach to the Postpartum Office Visit. American Family Physician 2005; 72:

2491-6, 2497-8)2491-6, 2497-8)Dennis, C-L; Hodnett, E; Cindy-Lee. Psychosocial and psychological interventions for treating postpartum depression 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.(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.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 Ferber SG, Granot M, Zimmer EZ. Catastrophizing labor pain compromises later maternity adjustments. Am J Obstet

Gynecol 2005; 192: 826-31.Gynecol 2005; 192: 826-31.Hoffbrand S, Howard L, Crawley H. Antidepressant treatment for post-natal depression. Cochrane Database Syst Rev. Hoffbrand S, Howard L, Crawley H. Antidepressant treatment for post-natal depression. Cochrane Database Syst Rev.

2001;(2):CD002018.2001;(2):CD002018.Miller L. Postpartum depression. JAMA 2002; 287: 762-5.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 Morris-Rush JK, Freda MC, Bernstein PS. Screening for postpartum depression in an inner-city population. Am J Obstet

Gynecol 2003; 188: 1217-9.Gynecol 2003; 188: 1217-9.Adolescence 1996 Winter; 31(124): 903Adolescence 1996 Winter; 31(124): 903Am J Obstet Gynecol 2005 Feb; 192(2): 522Am J Obstet Gynecol 2005 Feb; 192(2): 522Am J Psychiatry 2006 Aug; 163(8): 1435, 1443Am J Psychiatry 2006 Aug; 163(8): 1435, 1443Arch Womens Ment Health 2007; 10(6): 259)Arch Womens Ment Health 2007; 10(6): 259)Arch Womens Ment Health 2006 Sep; 9(5): 273Arch Womens Ment Health 2006 Sep; 9(5): 273BMJ 2002 May 4; 324(7345): 1062BMJ 2002 May 4; 324(7345): 1062Can J Psychiatry 2000 Aug; 45(6): 554Can J Psychiatry 2000 Aug; 45(6): 554Cochrane Library 2007 Issue 4: CD006116Cochrane Library 2007 Issue 4: CD006116Early Hum Dev 2003 Aug; 73(1-2): 61Early Hum Dev 2003 Aug; 73(1-2): 61Lancet 1996 Apr 6; 347(9006): 930Lancet 1996 Apr 6; 347(9006): 930Lancet 1998 Jan 10; 351(9096: 109Lancet 1998 Jan 10; 351(9096: 109Lancet 2007 Nov 10; 370(9599): 1629Lancet 2007 Nov 10; 370(9599): 1629J Clin Nurs 2008 Feb 19 early onlineJ Clin Nurs 2008 Feb 19 early onlineJ Clin Psychiatry 2001 May; 62(5): 332J Clin Psychiatry 2001 May; 62(5): 332Obstet Gynecol 2005 Jun; 105(6): 1442Obstet Gynecol 2005 Jun; 105(6): 1442Obstet Gynecol 2005 Nov; 106(5): 1071Obstet Gynecol 2005 Nov; 106(5): 1071Obstet Gynecol 2007 Nov; 110(5): 1102Obstet Gynecol 2007 Nov; 110(5): 1102Psychosom Med 2006 Mar-Apr; 68(2): 321Psychosom Med 2006 Mar-Apr; 68(2): 321