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Case Report
Postpartum Depression: Making the Case for Routine Screening
Aaron Keshen* B.Sc, and Joanne L. MacDonald M.D.
*To whom correspondence should be addressed: Aaron Keshen, 1041
Wellington St., #400, Halifax, NS, B3H 4P5; Telephone: (902)-444-
2997; akeshen@hotmail.com
CASE REPORT
Mrs. R is a 29-year-old woman primipara who presents for a routine check-up
6 weeks postpartum. Her history and physical are unremarkable
except that during the past month she has found it harder to concentrate
on simple
tasks, such as making the baby's formula. Also, despite always
feeling exhausted, she has been having trouble falling asleep after the
baby has
been put to sleep. When questioned about her mood, she replies, "I
feel fine", but offers little else. You know that these complaints
may be symptoms of postpartum depression (PPD), but because they
are non-specific, often non-pathologic (especially postpartum)
and she denies feeling depressed,
you are not sure whether the clinical presentation warrants a
more thorough investigation of Mrs. R's mental state. Should
you investigate more thoroughly?
If so, instead of taking a lengthy psychiatric history, what
fast and effective methods could be used to explore the possibility
that this patient
has, or is at risk of developing PPD? Also, what are the current
guidelines for diagnosing and treating PPD?
DISCUSSION
At least 10% of mothers will suffer from postpartum depression (PPD)
(1,2,3) a debilitating condition that is defined as a Major Depressive
Episode, which has an onset within 4 weeks postpartum (See Table
1 for the DSM-IV4 diagnostic criteria and differential diagnosis for PPD).
Although
clinicians have come to accept the view that PPD is a common
and serious medical condition, they are still debating the ideas concerning
the etiology
of the illness. Biological theorists have suggested that postpartum
fluctuations in hormones and/or other biological factors are responsible
for causing
PPD (1,2,3) Psychological models have also attempted to explain
the etiology of PPD. For instance, the cognitive model suggests that factors
such as
low self-esteem and dysfunctional relationships predispose the
mother to depression, which is then precipitated by postpartum stress
(1). Although
evidence exists for both biological and psychological theories,
conflicting data has made it impossible to definitively claim that any
one of these
theories is alone capable of explaining the etiology of PPD (1).
Instead, research suggests that a multifactorial etiology, which includes
both
biological and psychological factors, is probably responsible
for the illness (8).
While the etiology of PPD is still debated, the implications
of accurately diagnosing the condition remains important for
the immediate and long-term mental health of the mother (1),
her spousal relationship
and even the cognitive and behavioral developmentof her child
(1,2). Since PPD detrimentally affects so many lives, it is
unfortunate that many cases go undiagnosed (1,2). One major
reason for under diagnosis
is that many physicians only inquire casually about a new mother's
mental state (1,2) In addition, there are several reasons why
some mothers with
PPD will not disclose their symptoms. One reason is that there
is still a stigma surrounding mental illness. Another reason
is that some women
harbor guilt about feeling depressed during a period when they
are expected to be blissful (1). Yet another reason is that
some women assume that
they should experience some physiological changes (e.g. insomnia)
during the first few postpartum months, and are therefore embarrassed
to "complain" about
certain symptoms to their family doctors (16).
Definition of PPD
The DSM-IV4 defines PPD as a Major Depressive Episode*,
which has an onset within 4 weeks postpartum.
In order for the diagnosis to be made at least five
of the symptoms (see Box 1) must be present,
one
of which must be depressed mood or diminished
pleasure or interest in activities. The symptoms
must be present
most of the day nearly every day for two weeks.
Also, there must be an associated decline in social
and
/or occupational functioning.
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Differential Diagnosis of PPD
Baby Blues
In order for the diagnosis of PPD to apply, the
DSM-IV criteria must be met for 2 consecutive
weeks.4 If
the symptoms are observed for less than 2 weeks,
then a
diagnosis of "baby blues" is more appropriate.
(16) "Baby
blues", which is experienced by approximately
80% of new mothers, usually lasts for hours to
days, and in most cases resolves spontaneously
by the 10th
postnatal day.
Postpartum Psychosis
Postpartum psychosis is a medical emergency that
affects about 0.2 percent of new mothers.16
Symptoms usually
begin by the first postpartum month and resemble
those seen during a manic episode (i.e. insomnia,
agitation,
irritable mood, hallucinations and delusions).4
If hallucinations and/or delusions are present
they often
involve the infant, and can lead to harm directed
towards self or the infant.
General Medical Conditions that Present Like
Depression
In particular, thyroid disorder and anemia
can be exacerbated postpartum, and should
therefore be ruled out with
a careful history, physical, and appropriate
laboratory tests.
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Suicide Risk Assessment
As with other forms of depression, the risk of
suicide is increased for women with PPD.(16) For
this reason,
it is essential to determine whether a patient
with PPD is considering suicide. The first step in
a suicide
risk assessment should be inquiring about passive
ideation . One way to do this is by asking, "Have
you felt so low that you've thought life is not
worth living?" If an affirmative answer is
given, the active intent/plan should be determined.
This
can be done by asking, "Have you ever thought
of how you might end your life?" or "what
types of things have you considered doing?" If
the patient does have active intent, you should
ask whether they have the means to carry out the
plans
they have devised. If you are concerned that a
patient is a suicide risk, you should insist that
they go
to the hospital for psychiatric evaluation. If
they refuse, and you suspect they are truly a threat
to
themselves, you must notify the authorities.
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Symptoms of PPD*
- Depressed mood
- Diminished pleasure or interest
in activities
- Sleep disturbance (insomnia or
hypersomnia)
- Weight loss or weight gain
- Psychomotor
agitation or retardation
- Loss of energy
- Feelings
of worthlessness or inappropriate guilt
- Diminished
concentration, or indecisiveness
- Frequent
thoughts of death or suicide
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| *See the DSM-IV4 for a more detailed
description of the diagnostic criteria and symptoms
of depression. |
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| Table 1. Diagnosing Postpartum Depression |
Since it is beneficial for physicians to explore the issue of PPD more
thoroughly, what fast and effective methods can be used to accomplish
this goal? Two accepted approaches that can be used concomitantly
are: a) routine screening of all postpartum mothers and b) heightened
attention
to the risk factors for PPD. The next section of this paper describes
how these two methods can be used effectively to increase the
detection of this devastating disease.
Routine Screening and Risk Factors for PPD
One way for physicians to explore the issue of PPD is to routinely
screen all postpartum mothers, a procedure that is very
easy and effective, but for unknown reasons is almost never used
(1). Among various screening tests for PPD, experts consider
the Edinburgh
Postnatal Depression Scale (EPDS) (1) to be the best choice
in terms of its ease of administration, validity, specificity
and
sensitivity (16,19,1,2,38) (See Table 2 for the EPDS scale
and guidelines for raters.) This scale has been validated
using standardized
psychiatric interviews and translated into fourteen languages
(19,1,2,3). Furthermore, evidence from four studies has
confirmed that the tool is approximately 86% sensitive and 90% specific
for PPD. These are impressive statistics when one considers
that the test consists of only 10 multiple choice questions
and takes
mothers less than 5 minutes to complete (16,19). As further
evidence of the scale's effectiveness, one study showed
that
routine screening
with the EPDS in family practices increased the rate of
diagnosis of PPD from 3.7% to 10.7% (18)
Guidelines for Raters (19)
- The mother is asked to underline the response
which comes closest to how she has been feeling
in the
previous 7 days.
- All ten items must be completed.
- Care should
be taken to avoid the possibility of the mother
discussing her answers with others.
- The mother
should complete the scale herself, unless she
has limited English or has difficulty
with reading.
- The child health clinic, postnatal check-up
or a home visit may provide suitable
opportunities for
its completion.
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Scoring the EPDS
Response categories are scored 0, 1, 2, and 3 according
to increased severity of the symptoms. Items
marked with an asterisk are reverse scored
(i.e. 3, 2, 1, and 0). The total score is calculated
by adding together the scores for each of the ten
items. Individual items are totalled to give
an
overall score. A score of 12+ indicates the likelihood
of depression (with about 90% specificity and 86%
sensitivity), but not its severity
(19,22,23,24). If a women scores 12+, this warrants
a full psychiatric history during which a DSM-IV
diagnosis of PPD is considered. A woman
who scores 5-11 should be evaluated again in 2-4
weeks in order to assess whether there has been a
worsening
of symptoms. A patient who scores
less than 12 on the EPDS, but scores 3 or 2 on Question
10 warrants a full psychiatric evaluation. The EPDS
Score is designed to assist, not
replace clinical judgement.
Users may reproduce the scale without further permission
providing they respect copyright by quoting the
names of the authors, the title and the
source of the paper in all reproduced copies.
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Edinburgh Postnatal Depression
Scale(19)
As you have recently had a baby, we would like
to know how you are feeling. Please UNDERLINE the
answer which
comes closest to how you
have felt IN THE PAST 7 DAYS, not just how you feel
today.
1. I have been able to laugh
and see the funny side of things.
- As much as I always could
- Not quite so much now
- Definitely not so much now
- Not at all
2. I
have looked forward with enjoyment to things.
- As much as I ever did
- Rather less than I used to
- Definitely less than I used to
- Hardly at all
3. * I have blamed myself unnecessarily
when things went wrong.
- Yes, most of the time
- Yes, some of the time
- Not very often
- No, never
4. I have been anxious or worried
for no good reason.
- No, not at all
- Hardly ever
- Yes, sometimes
- Yes, very often
5. * I have felt
scared
or panicky for not
very
good reason.
- Yes, quite
a lot
- Yes,
sometimes
- No,
not much
- No,
not at
all
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6. * Things have been getting
on top of me.
- Yes, most of the time I haven't been able
to cope at all
- Yes, sometimes I haven't been coping
as well as usual
- No, most of the time I have coped quite
well
- No, I have been coping as well as
ever
7. * I have been so unhappy that
I have had difficulty sleeping.
- Yes, most of the time
- Yes, sometimes
- Not very often
- No, not at all
8. * I have felt sad or miserable.
- Yes, most of the time
- Yes, quite often
- Not very often
- No, not at all
9. * I have been so unhappy that
I have been
crying.
- Yes, most of
the time
- Yes, quite
often
- Only
occasionally
- No,
never
10.
* The
thought of
harming myself
has occurred
to me.
- Yes,
quite often
- Sometimes
- Hardly
ever
- Never
(Taken
from the
British Journal
of Psychiatry,
June, 1987,
Vol. 150
by
J.L. Cox,
J.M. Holden,
R. Sagovsky) |
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| Table 2. Edinburgh Postnatal Depression
Scale (EPDS)19 and Guidelines for Raters |
In addition to routinely screening postpartum mothers, physicians can
further explore the possibility of PPD by asking patients about the risk
factors for the illness. This is an effective strategy because certain
risk factors are very strong predictors of whether a patient is susceptible
to PPD (33-37). Some important risk factors for physicians to keep in
mind are included in Table 3.
- History of depression prior
to conceiving (3).
- History of PPD in previous pregnancies (3).
- Family history of depression (32).
- Few supportive family members or friends (3).
- Financial or housing difficulties (3).
- Severe premenstrual syndrome (35).
- Dysfunctional spousal relationship (34,3).
- Other stressful life events during the pregnancy
or after the childbirth (3).
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| Table 3. Risk Factors for PPD |
Management of PPD
The management of PPD parallels that of Major Depressive Disorder; however,
there are some special management considerations for patients with PPD
(1,2,3,4,5). Some of these considerations are described in Table 4.
Mild PPD
Symptoms that barely fulfill the DSM-IV diagnostic
criteria for PPD and cause a minor impairment
of social/occupational functioning.
Individual interpersonal
therapy or group counselling, and couples therapy
if marital discord is a factor. Also, patient
education materials should be provided for the
mother and
spouse
(16)
If there is no response to talk therapy,
consider adding a SSRI or tricyclic antidepressant*.
If
the depression worsens, or there are suicidal/infanticidal
thoughts, or symptoms of psychosis, or inadequate
response to an antidepressant, then refer
to a psychiatrist (16). |
Moderate/Severe
PPD
Symptoms in excess of the bare requirements to
fulfill the DSM-IV diagnostic criteria
for PPD and cause
a major impairment of social/occupational functioning.
Consider a SSRI or tricyclic
antidepressant* +/- individual interpersonal
therapy or group counselling, and couples therapy
if marital
discord is a factor. Also, patient education
materials should be provided for the mother and
spouse (16)
If the depression worsens, or there are suicidal/infanticidal
thoughts, or symptoms of psychosis, or inadequate
response to an antidepressant, then refer
to a psychiatrist (16) |
Notes on antidepressant
administration
Selective serotonin-reuptake inhibitors (SSRIs)
(25,27), venlafaxine (28) and tricyclic antidepressants
(TCAs) (29) have been shown to be more
effective than placebo for treating PPD, and are
therefore considered to be appropriate therapy for
PPD. Fluoxetine was shown to be as effective
as psychotherapy for treating PPD (27).
SSRIs or venlafaxine should be considered
as first-line drug therapy rather than TCAs because
they are associated
with a lower risk of toxic
effects in patients who have taken an overdose
(3). Also, women with PPD are more likely to have
a response
to SSRIs or venlafaxine than to
TCAs (25,28,29) However, TCAs should be considered
for women who have responded to them in the past
(38).
Administration of TCAs or SSRIs is not contraindicated
during breastfeeding. However, small amounts of
the drugs do reach the infant via
breast milk. Since the long-term effects of this
exposure are not known, parents should make informed
decisions that are documented in their
medical records. It should be emphasised to women
with moderate/severe depression, women who have
not responded to psychotherapy, and
women who are suicidal, infanticidal or psychotic
that the benefits of taking antidepressants are
considered to outweigh the risks of exposure to
the infant.
If an exposed infant seems irritable, plasma concentration
of the drug should be determined and appropriate
dosage adjustments made (38).
Antidepressant therapy should be started at the starting
doses used for nonpuerperal depression. Once
a full remission is achieved, therapy
should continue for a minimum of six months, in
order to prevent relapse (38).
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| Table 4. Management of PPD |
Case Revisited
Since casual inquiry may not reveal PPD symptoms that Mrs. R
could be experiencing, you decide to investigate her complaints
more thoroughly. You screen Mrs. R using the EPDS and she has
a score of
14, which suggests that there is a 90% probability that she
suffers from PPD. She also has several of the risk factors
for the condition (i.e. marital discord and financial difficulties),
which corroborates
the positive EPDS score. Because of the high probability
that Mrs. R
has PPD you take a detailed psychiatric history during which
you apply the DSM-IV criteria of PPD, and also rule out disorders
that present
like PPD.
You determine that she does in fact have moderate PPD, so
you recommend SSRI antidepressant administration, with
follow-up within 2 weeks to assess side effects and response. As well,
you provide her and
her husband with patient education materials. You also initiate
or make a referral for individual and relationship therapy
if functioning or insight remains seriously impaired.
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Aaron Keshen is a third year medical student from Dalhousie University,
Halifax, N.S. Dr. Joanne L. MacDonald, MD, FRCPC, is with the
Reproductive Psychiatry Consultation Service, Maternal Health Program,
IWK Health Center,
Halifax, N.S.
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