Postpartum Depression Information and Resources
As many as 50 percent to 80 percent of new mothers may experience the postpartum blues (Epperson, 1999; Kennedy, Beck and Priscoll, 2002; Miller 2002). Emotional lability is the prime characteristic. Happy one moment, the woman may dissolve into tears the next. Additionally, she may experience anxiety, irritability, fatigue and, occasionally, confusion.
The onset is typically around the time the mother's milk comes in, three to four days postpartum. Symptoms may persist for only hours or last for up to a week.
Perhaps because the symptoms are usually mild and transitory, little is found in the literature regarding helpful interventions. Many providers try to provide some anticipatory guidance so that women do not become frightened when experiencing minor mood swings. Sleep also seems to be useful in restoring mood balance. Arrangements for family or friends to provide a few hours of child care so that the new mother can get some uninterrupted sleep may be the best support.
Although for most women the postpartum blues represents a small "bump" in the initial adjustment, it should be noted that up to two-thirds of women who later develop true depression have experienced an episode of postpartum blues. Similarly, women who reported a marked "high" or euphoria after birth may also be more likely to receive a subsequent diagnosis of postpartum depression (Glover, 1994).
Postpartum Depression
As many as 23 percent of women may experience a true, major depression after childbirth (Miller, 2003). The incidence may be higher among adolescent mothers (Kennedy, 2001). The onset may be abrupt and severe or it may be more insidious. Opinions vary with regard to the time of onset for the diagnosis of true postpartum depression. Historical definitions stipulate onset within four weeks of childbirth, but many authors recognize the onset of postpartum depression as long as six months, lasting up to one year after delivery (Miller, 2002; Kennedy, Beck and Driscoll, 2002). It is critical to note that later onset would coincide with a period of time (from the six-week postpartum exam to the next annual exam) when the woman would be unlikely to see her primary care provider routinely. It is important, then, that CHN or pediatric providers who might have contact with the mother during this time be especially attuned to depressive symptoms.
Left untreated, depression may have lasting effects on the woman's self confidence as well as a significant impact upon the maternal-child relationship and the infant's development. Babies as young as 3 months old perceive alterations in their mother's affective quality and begin to respond with their own behavioral changes. Negative changes in cognitive skills, expressive language development and attention have been documented in the infants of mothers with postpartum depression (Epperson, 1999; Misri and Kostaras, 2002).
Risk Factors
Risk factors for postpartum mood disorders are reasonably intuitive. Those
women who have less social support, are in stressful relationships, experience
child care difficulties, are having an unplanned or unwanted infant, and/or
who are unpartnered are more susceptible to disturbance. Low self esteem,
a history of a previous mood disorder, especially bipolar disorder, and
prenatal depression or anxiety are also considered to be risk factors.
Up to 60 percent of women with known bipolar disorder will relapse in
the postpartum period. There is a 30 percent recurrence risk in those
who have had a previous postpartum mood disorder. Further, there is a
high incidence of non-puerperal relapse of depression (Epperson, 1999).
Interestingly, obstetrical events have not consistently been associated with the development of postpartum depression. Mode of delivery, obstetrical complications and the like do not seem predictive.
Diagnosis
Referral to a licensed mental health provider is necessary for diagnosis
of postpartum depression. There is no separate diagnostic category for
depression that occurs after delivery. There is a modifier of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV) diagnostic code for
major depression that indicates postpartum onset. The symptoms are the
same as those that characterize depression at any stage of life and include:
- Depressive mood
- Lack of pleasure
or interest
- Sleep disturbance
- Weight loss
- Loss of energy
- Agitation or retardation
- Feelings of worthlessness
or inappropriate guilt
- Diminished concentration
or indecisiveness
- Thoughts of death or suicide
It is important to note that at least three of these symptoms (sleep disturbance, weight loss and loss of energy) are considered, in some degree, typical of the postpartum period. As a result, delay in the recognition of symptoms may occur. The mother, expecting some degree of postpartum "adjustment," may not realize that her symptoms have become more than what should be expected. Unfortunately, even if she recognizes that she is struggling, it may be difficult for her to seek help. Societal pressures to be "super-mom" are hard to ignore.
It is also critical that medical as well as psychiatric evaluation be obtained for women experiencing these symptoms. Metabolic disorders, most notably hypothyroidism, must be ruled out. As many as 5 percent of postpartum women will experience a brief episode of hypothyroidism in the postpartum period (Epperson, 1999).
Screening
There have been multiple attempts to identify screening instruments that
are both specific (truly identifying only those with postpartum depression)
and sensitive (identifying all of those with postpartum depression). Some
instruments are designed to be used prenatally to predict who is at risk
for depression and others are designed to be administered in the postpartum
period to screen for the actual existence of depression. The important
message is that screening and diagnosis need to occur as early as possible,
before significant harm to the maternal/infant relationship and to the
family unit occurs. Some commonly cited tools are listed below.
The Edinburgh Postnatal Depression Scale is cited in much of the literature. It has commonly been tested and used throughout the United Kingdom and Europe. It is a 10-item, self-report instrument that takes less than five minutes to complete. Validation study has shown that a score above 92.3 percent indicates a strong likelihood of depression of varying severity. This instrument is available on the Internet and is for use in screening during the postpartum period. Simply type "Edinburgh Postnatal Depression Scale" into a search engine (e.g., Google). It is also published in the British Journal of Psychiatry, June 1987, Volume 150. The authors are Cox, Holden and Sagovsky.
The Beck Postpartum Depression Predictors Inventory - Revised (PDPI - II) is an instrument designed to be used antenatally as well as postpartally to identify risk factors for postpartum depression. This instrument is not self-report, but is designed to be used as an interview tool for the clinician. The author recommends screening during each trimester as well as within six weeks of delivery. It assesses risk factors in the following areas: prenatal depression, life stress, social support, prenatal anxiety, marital relationships, depression history, self-esteem, planned/unwanted pregnancy, marital status, socioeconomic status, child care stress, infant temperament and maternity blues. A description of the development of this instrument, a comparison with other screening tools and the inventory itself is published in JOGNN (2002),Volume 31, Number 4, pps. 394-402. The author is Cheryl Beck, C.N.M., D.N.Sc., F.A.A.N.
Beck has also developed the Postpartum Depression Screening Scale (PDSS) for use in screening for postpartum depression after delivery. According to Beck, the PDSS is both more sensitive and more specific than either Postpartum Depression Predictors Inventory or the Edinburgh Postnatal Depression Scale in identifying women with postpartum depression. This instrument is self-report and can be administered in five to 10 minutes. It is copyrighted and must be purchased for use. It can be purchased through Western Psychological Services at 12031 Wilshire Boulevard, Los Angeles, CA, 90025-1251. (WPS also has a web site: www.wpspublish.com.) Beck is involved in research related to screening the Hispanic woman for postpartum depression. She has her own web page, which can be located by entering her name in a computer search engine.
A less commonly cited instrument is the Antepartum Questionnaire, a 24-item self-report questionnaire developed by Posner, Unterman and Williams. This questionnaire was published in the Journal of Reproductive Medicine (1997), Volume 42, pps. 207-215. These authors report a sensitivity of 80 percent and a specificity of 82 percent with their instrument.
Treatment
Early treatment of postpartum depression is a necessity. Both psychotherapy
and pharmacologic treatment have been shown to be effective (Epperson,
1999; Miller, 2002; Kennedy, Beck and Driscoll, 2002). However, many practitioners
believe that initial therapy should be pharmacological because response
occurs more quickly and the woman can resume her normal child care and
family responsibilities sooner. However, many of the relationship issues
that are associated with postpartum depression may need to be addressed
in counseling over the long term.
There are two classes of antidepressent medication that have been used commonly and are considered safe even for the breastfeeding mother. These are the classic tri-cyclic antidepressants (Tofranil, Elavil, Pamelor, Norpramin) and the Selective Seratonin Reuptake Inhibitors (Prozac, Zoloft, Luvox, Paxil). Although there are no controlled trials, there are multiple case series, case reports and pharmacokinetic studies that have revealed no adverse consequences in the use of these medications (Misri and Kostaras, 2002; Burtetal, 2001). Some authors have expressed reservations regarding the use of Paxil and Doxepin due to their long half-life.
There are very little data available on some of the less commonly used antidepressants and these should be avoided if possible. Included in this category are Bupropion (Wellbutrin), Traxodone (Desyrel), Venlafaxine (Effexor) and Buspirone (BuSpar). Similarly, herbal medication (St. John's Wort, Valerian and Kava) should also be avoided because they have not been found either efficacious or safe in the breastfeeding woman.
An article found in American Family Physician (1999), Volume 59, Number 8, provides a summary table of commonly used antidepressants, including starting dosage, usual daily dose, half-life, side effects and cost. Some authors caution that postpartum women should be started on a lower dose (Wisner, Parry, & Pointek, 2002), while others disagree (Epperson, 1999). Epperson's article, "Postpartum Depression: Detection and Treatment" is available online.
Sichel and Driscoll, in their book Women's Moods: What Every Woman Must Know About Hormones, the Brain and Emotional Health (1999), discuss another aspect of care beyond medication and therapy. Their psychosocially based model is summed in the acronym NURSE and includes:
1. Nutrition and needs
2. Understanding
3. Rest and relaxation
4. Spirituality
5. Exercise
The NURSE model serves as an excellent guide for the care provided by CHNs. These aspects of care can be incorporated at any time in the course of pregnancy or the postpartum period, and would likely benefit any woman in one's caseload.