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How do you define postpartum emotional disorders and what are their
symptoms?
As mentioned above, the three postpartum
emotional disorders are postpartum blues, postpartum depression, and
postpartum psychosis. Postpartum blues describes the weeping and emotional
lability which occur within the first two weeks postpartum. It is
a normal condition of heightened emotions. Symptoms include frequent
and prolonged crying, irritability, poor sleep, food cravings/loss
of appetite, mood changes, and a sense of vulnerability. Symptoms
generally resolve by postpartum week three. Postpartum depression
is still a poorly defined syndrome, generally understood as unusually
severe or prolonged postpartum blues. Symptoms of depression are generally
noted at 4-8 weeks postpartum and include despondency, tearfulness,
anhedonia, feelings of inadequacy, guilt, severe anxiety, irritability,
change in appetite, difficulty concentrating, and fatigue. Often the
mother will make multiple phone calls or visits to the pediatrician
for trivial complaints. Some mothers will even develop obsessive thought
patterns about their child’s health. Untreated, postpartum depression
will last 3-14 months. Postpartum psychosis is obviously the most
severe of the three disorders and is defined by the development of
disordered thought processes. Symptoms begin within several days of
delivery and may include confusion, disorientation, manic behavior,
agitation, hallucinations, and delusions. Postpartum psychosis is
a medical emergency where infanticide is a small but very real risk!
Immediate hospitalization of the mother is required.
2. I’m a pediatrician,
not a psychiatrist or an OB – do I actually have a role in diagnosing
PPD?
Absolutely. First of all, the presence
of maternal PPD can have a significant impact on your patient –
the child. Maternal PPD can significantly negatively impact maternal-infant
interaction and bonding. Other studies have shown that maternal depression
correlates with developmental and behavioral difficulties throughout
childhood, including the development of conduct and attention disorders.
Maternal PPD can also lead to impairments in social and cognitive
development through age four, as shown in certain studies by a decrease
in intelligence test scores. (Seidman, 1998). Secondly, many mothers
do not recognize their problem as depression and therefore do not
seek help. The new mother may also feel shame and guilt about her
feelings and will not discuss her feelings with anyone, especially
her child’s doctor. Also, she may not be aware that help is
readily available. Lastly, as mentioned above, you, as the pediatrician,
see the mother more than any other health professional (the postpartum
OB visit is at 6 weeks only) and therefore are more likely detect
the presence of PPD.
3. But how do I diagnose
post-partum depression?
There will be cases (as in the vignette)
where it is obvious that there is something amiss. In such cases,
a reasonable first question, even prior to asking any questions about
the baby, is “How are you doing – you seem very sad/ upset/
tired?” or open up the conversation with “What a beautiful
baby – it’s tiring/ challenging to have a new baby at
home isn’t it?” For other cases, a very simple screening
tool has been developed for the diagnosis of postpartum depression.
The tool is called the Edinburgh
Postnatal Depression scale, and studies have shown it to predict
up to 50% of cases of PPD. A study by Evins et al. showed that in
an OB/GYN residency program, the incidence of detection of PPD was
significantly higher when the Edinburgh was used compared to the incidence
of spontaneous detection during the course of the interview (35.4%
vs. 6.3%). This screen consists of ten questions that screen for anhedonia,
guilt, anxiety, coping ability, insomnia, feelings of despondency,
and suicidality. The responses are scored from zero to three points
where a response earning zero points indicates a total lack of the
above feelings whereas a score of three indicates that the mother
is experiencing these feelings very often. A total score of 10 or
more is suggestive of postpartum depression. The screen should be
performed at the 2 week, 2 month, and 4 month visits. See below for
a copy of the screen.
4. OK….so I diagnosed
the patient in the vignette above with postpartum depression. Now
what do I do?
First and foremost, gently tell the mother that the symptoms she is
experiencing are consistent with a postpartum emotional disorder.
Remind her that this is very common and does not mean that she is
“crazy.” For a woman with postpartum blues, this may be
sufficient. In addition, there are national and international postpartum
support groups that can be contacted. The two largest groups are Postpartum
Support International (http://www.chss.iup.edu/postpartum)
and Depression after Delivery (http://www.depressionafterdelivery.com).
For more difficult cases referrals should be made
to a support group such as one that is currently being formed through
the Alianza Dominicana and/or to a psychiatrist. If possible, urge
the mother to find someone to help her with the newborn to remove
some of the emotional and physical strain. If the psychiatrist deems
it necessary, pharmacologic therapy may be initiated. Sertraline (Zoloft)
seems to be the drug of choice as it is not excreted in breast milk,
thus allowing nursing to continue. If your patient is started on an
SSRI, remind them that it may take 1-3 weeks before any improvement
is noted.
5. Will the mother be permanently
depressed?
Most mothers recover completely, although some mothers with postpartum
psychosis never fully recover. 60% of women with postpartum depression
will have a recurrence with subsequent pregnancies. Interestingly,
if treatment with an anti-depressant is begun within 24 hours of delivery
that risk is reduced to only 6.7%.
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