postpartum%20depression
POSTPARTUM DEPRESSION

Postpartum depression is the occurrence of a major depressive episode within 4 weeks following delivery or up to a year after childbirth.

It may peak at 2-4 weeks and 10-14 weeks after childbirth.

Symptoms are similar to that of major depression but with additional features distinctive of the postpartum period like feelings of being overwhelmed and inadequate as a parent.

Postpartum%20depression Diagnosis

Assessment

  • Assess all women for symptoms of depression and anxiety at least once during postpartum check-ups (preferably at each visit)
    • Simultaneously screen also for bipolar disorder as management of this condition is different from PPD, ie potential antidepressant therapy may worsen bipolar disorder
  • It is important to identify PPD in the patient as this leads to serious consequences for the patient, infant and her family (eg decreased functioning of the patient with increased risk of relationship conflicts, and infant caregiving as well as the cognitive, emotional and social development of the child are affected)
  • It also helps in identifying patients who would need specialized care as early detection and intervention are important

History

  • Due to the high rates of psychiatric comorbidity, inquire specifically about a family or personal history of mental health disorders (eg depression, bipolar disorder, postpartum psychosis, anxiety, panic or obsessive-compulsive disorders) and relevant social history (eg substance or alcohol abuse, living conditions, economic status, quality of interpersonal relationships, violence and abuse from partner, childhood maltreatment)
  • Ask if patient has thoughts of harming herself or anyone else and if able to care for herself or the infant

Screening

  • The U.S. Agency for Healthcare Research and Quality and the United Kingdom’s National Institute for Health and Care Excellence recommend use of a 2-question screening tool relating to feelings of hopelessness or depression and lack of pleasure or interest in activities in the past month
    • A positive answer to either question can be followed by the use of the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire 9 (PHQ-9) to identify possible PPD
    • Positive results from the questionnaires (eg a score of >10 or a positive reply to having thoughts of harming oneself in the EPDS) should lead to a complete clinical interview with the patient to confirm diagnosis using the DSM-5 criteria

Diagnostic Criteria

  • The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for postpartum depression have a peripartum onset specifier (ie onset of depressive symptoms occurs during pregnancy or within 4 weeks after delivery) that can be applied to major depressive episode criteria
    • A major depressive episode requires that at least 5 or more of the following symptoms (one of which must either be depressed mood or diminished interest or pleasure in activities) must be present for most of nearly every day for 2 weeks
      • Depressed mood that is either self-reported or observable
      • Diminished interest or pleasure in activities
      • Hypersomnia or insomnia
      • Changes in appetite, weight gain or weight loss (when not dieting)
      • Feeling of fatigue or loss of energy
      • Psychomotor agitation or retardation
      • Sense of diminished or loss of self-worth and inappropriate guilt
      • Diminished ability to concentrate or make decisions
      • Recurrent thoughts of death or suicidal ideation (with or without a specific plan)
    • The depressive symptoms cause significant impairment or distress in social, occupational or other areas of function, are not caused by the physiological effects of a substance or another medical condition, not better explained by a schizoaffective disorder or other psychotic disorders, and there has never been an episode of mania or hypomania

Symptom Severity

  • Severity of symptoms may be estimated based on its impact on patient’s daily functioning
    • Mild depression: Meets minimal depression diagnostic criteria and can function with extra effort
    • Moderate depression: Meets depression diagnostic criteria and cannot overcome symptoms with extra effort but not incapacitated
    • Severe depression: Meets diagnostic criteria and has incapacitating symptoms

Physical Examination

  • Conduct a mental status exam and complete physical exam for other medical causes
  • Patient may present with poor hygiene and rapid weight loss (self-neglect), lacerations or scars (self-harm), flat affect, slow movement/speech or restlessness (psychomotor retardation or agitation)

Laboratory Tests

  • Measure hemoglobin and thyroid-stimulating hormone levels to screen for anemia and thyroid dysfunction as both conditions can imitate depression

Differential Diagnosis

  • Baby Blues
    • Develop mostly in new mothers with typical symptoms (eg crying spells, mood swings, and anxiety) appearing between 3-5 days after childbirth and resolving within 2 weeks without treatment, though some may progress to PPD
  • Postpartum Psychosis
    • Considered to be a psychotic episode of bipolar disorder, postpartum psychosis typically starts within the first days or weeks after childbirth with symptoms of bizarre behavior, confusion, delusions, disorganized thoughts, hallucinations, and depressed or elevated mood
    • Mania starts within 2 weeks postpartum with depression developing later on
    • An emergency due to the possibility of suicide or harm to the infant
  • Other conditions that need to be ruled out include anxiety disorder, obsessive-compulsive disorder, panic disorder, bipolar disorder, substance or alcohol abuse, anemia, hypothyroidism
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