The Recognition & Treatment of Postpartum Depression

1. The Recognition & Treatment of Postpartum Depression Johna M Bott Eileen Van Dyke 3/23/06

2. PPD • Characterized by despair, sadness, anxiety, fears, compulsive thoughts, feelings of inadequacy, loss of libido, fatigue, & dependency • Affects upwards of 20% of women after childbirth • Major health problem that threatens the family unit as a whole

3. Postpartum psychosis • Emergency that requires immediate hospitalization • Presents with mania, psychotic thoughts, severe depression • Rare occurring in 1-2 deliveries out of a thousand

4. Why do we care? • Affects entire family unit, not just the mother • One mother described PPD as being buried alive with no chance of clawing to the surface • While mom is debilitated, child’s cognitive and social development suffers then & potentially later on in life with the development of conduct & attention disorders • Fathers also affected by stress put on marriage

5. PPD screening is not being done

6. Screening • Approximately 50% of PPD cases go undiagnosed • Although family physicians believe PPD is serious, identifiable, and treatable, screening is still not standard clinical practice in the US • Clinical signs are often not apparent unless screened for • Screening tools are out there & some are even specific for PPD

7. Excuses • OB screens for that • Pediatricians screen for that at well baby visits • There are too many tools out there, I don’t know which one to use • The tools are too complex • Is that my job?

8. Risk Factors • Prenatal depression • Totally independent of time • Any depression during pregnancy was discovered to be a significant predictor

9. Risk Factors • Child care stress • Childbirth itself is a traumatic stressful event that makes the mother more vulnerable to other stressors • Any stressful event involving the care of the newborn, including the temperament of the baby which may be fussy, irritable, and difficult to console • Unhealthy infants

10. Risk Factors • Support or lack there of • Social, emotional, and instrumental support is very important for new mothers and either perceiving a lack of it or actually having a lack of it can be very detrimental

11. Risk Factors • Life stress • The number of both positive and negative stressful life events that occur during pregnancy and the postpartum period

12. Risk Factors • Prenatal anxiety • Marital dissatisfaction • History of previous depression • Affective illness or previous PPD episode

13. Medical Problems with Related Sx • Transient hypothyroidism • Anemia • Diabetes • Other endocrine disorders • Abuse situations • Infection

14. Treatment Options • Individual psychotherapy • Personalized care • Scheduling flexibility • Group therapy • Not for everyone • Compliance issue with scheduling conflicts • Need adequate # to participate

15. Treatment Options • Pharmacologic treatment • Selective serotonin reuptake inhibitors (SSRIs) • All antidepressants are secreted in breast milk • Continued at least six months to ensure complete remission • Complementary or alternative treatments • Bright-light therapy, exercise, massage therapy, & chronobiological therapies, such as wake therapy

16. Treatment Options • Controversial therapies • Progesterone or estrogen injections • Hospitalization • Risk of suicide or infanticide • Antipsychotics • Electroconvulsive therapy

17. Available Screening Tools • The Beck Depression Inventory • The Bromley Postnatal Depression Scale • The Center for Epidemiological Studies Depression Scale • The General Health Questionnaire • The Inventory of Depressive Symptomatology • The Zung Self-Rating Depression Scale • The Edinburgh Postnatal Depression Scale • The Postpartum Depression Screening Scale

18. The Edinburgh Postnatal Depression Scale • One of the best known screening scales for PPD • Measures emotional and cognitive symptoms of PPD • Ten items scored from 0 to 3 • Only somatic sx taken into account is sleeping difficulties • Available in multiple languages

19. The Postpartum Depression Screening Scale • Measures 7 dimensions of PPD including sleeping/eating disturbances, anxiety/insecurity, emotional liability, cognitive impairment, loss of self, guilt/shame, & contemplating harming oneself • 35 items • Excellent sensitivity & specificity

20. Conclusion • The general consensus is that both the EPDS & the PDSS are good screening scales for PPD • Practitioners may form personal preferences due to length or detail of questions • Most important thing is that a screening method is used

21. Summary • PPD is real & very serious • Talking about PPD openly might make it less scary, educate the patient & their family • Screening at every visit is the key to the difficult recognition that is due to drastic differences in symptoms from patient to patient • Prompt treatment with effective follow-up

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