Postpartum Depression Symptoms Diagnosis and.9

50 JAAPA • FEBRUARY 2013 • 26(2) • www.jaapa.com

Genevieve A. DelRosario, MHS, PA-C; A. Caroline Chang, MMS, PA-C; Elizabeth D. Lee, BA

The birth of a baby is usually an eagerly awaited and joyful event and a milestone in the life of a family. Many women are surprised, then, when this joyful event is followed by sadness, mood swings, and anhedonia. This

response should not, however, be a surprise to medical pro-viders. Postpartum depression (PPD) is the most common complication of childbearing, occurring in approximately 15% of women during the postpartum period, with some sources suggesting that the true incidence may be higher.1-4 The potential impacts on the mental and physical health of the mother and her infant may be profound and lifelong, as bonding, preventive care, and health maintenance are often suboptimal during the fi rst few critical months of life. Beyond the clinical implications for both the mother and her infant, direct and indirect fi nancial implications of this condition are substantial as well.5

Given the frequency and severity of PPD, all medical providers should recognize the signs of PPD and know the basics of therapy. In particular, PAs working in obstetrics and gynecology, pediatrics, and family and emergency medicine should be knowledgeable regarding this common complication. This article will review the pathophysiology, risk factors, signs and symptoms, diagnosis, treatment, and sequelae of postpartum depression.

DEFINITIONSThe defi nition of perinatal depression differs from other forms of depression only in terms of timing. The Diagnostic and Statistics Manual, Fourth Edition, Text Revision

Postpartum depression: Symptoms, diagnosis, and treatment approachesMaternal depression folowing the birth of a baby can impact the quality of life of both mother and child over the course of their lifetimes and may have life-threatening effects.

CME LEARNING OBJECTIVES Differentiate postpartum depression (PPD) from the “baby blues” and postpartum psychosis. ●

Apply standardized instruments for objective screening for PPD as a routine part of care. ●

Discuss appropriate alternatives for the management of patients with PPD. ●

Identify common complications of unrecognized and improper treatment of patients with PPD. ●

EARN CATEGORY I CME CREDIT by reading this article and the article beginning on page 26 and successfully completing the posttest on page 55. Successful completion is defi ned as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of February 2013.

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(DSM-IV-TR) defi nes postpartum depression by adding a specifi er to the discussion of major depressive disorder (MDD), citing an onset of depressive symptoms within 4 weeks of giving birth.6 Clinically, however, PPD is often diagnosed when symptoms occur within 12 months of a child’s birth.2

Most women will experience mood swings, commonly called the baby blues, in the weeks following the birth of a child. This condition is usually mild and transitory, resolv-ing in the fi rst 10 days of an infant’s life, and is not accom-panied by suicidal ideation.2 The practicing PA should be diligent in differentiating between this common occurrence and a true major depressive episode. Additionally, patients and their partners should be educated regarding warning signs of a true depressive disorder and encouraged to con-tact their medical provider if signifi cant concerns arise.

All clinicians, especially those practicing in primary care fi elds and emergency medicine, must be able to differentiate the more serious postpartum psychosis from these other condi-tions (Table 1). Postpartum psychosis has a rapid onset, gen-erally occurring within the fi rst 4 weeks after childbirth but in some cases as early as 2 days postpartum. Patients may devel-op paranoid, grandiose, or bizarre delusions; mood swings; confused thinking; and disorganized behavior, all of which vary from their normal state. In many cases, postpartum psy-chosis is a manifestation of bipolar disorder. The disorder is a psychiatric emergency in which the safety of the new mother and her child or children may be jeopardized; for example, a mother may hear voices telling her she should kill her infant. Immediate treatment, including hospitalization, must be con-sidered for this population.7

PATHOPHYSIOLOGY OF PPDDespite increasing awareness of PPD, little is known about its specifi c etiology. Suggested mechanisms include changes in estrogen, progesterone, serotonin, monoam-ine oxidase A (MAO-A) and gamma-aminobutyric acid (GABA) levels.3,5,8,9 Alternations in the hypothalamic-pituitary axis and thyroid dysfunction have also been considered, as well as decreased levels of the omega-3 polyunsaturated fatty acid (PUFA) docosahexaenoic acid (DHA).1,4,9,10 Furthermore, promising epigenetic studies suggest that genetic predisposition may play a signifi cant

role in a woman’s response to environmental factors regard-ing PPD development.4,11

Elevated levels of estrogen and progesterone that are present in the third trimester of pregnancy are known to drop expo-nentially early in the postpartum period.9 Estrogen appears to affect serotonin levels and serotonin receptors both directly and secondarily through MAO-A levels,3,5 while progesterone appears to affect GABA-A receptors.3,8 Given estrogen’s effect on MAO-A levels, there is further potential for a secondary effect on dopamine and norepinephrine levels.3 Because serotonin, MAO-A, and GABA have well-documented rela-tionships with psychiatric diseases,3,8 hormonal shifts may con-tribute to an episode of PPD in predisposed individuals.

Although decreased activation of the hypothalamic-pituitary axis after childbirth has been hypothesized as a contributing factor in the development of PPD, an exact mechanism remains unclear.9,12 In addition, approximately 6% to 9% of women develop postpartum thyroiditis, which may present with symptoms of either hyperthyroidism or hypothyroidism. Because depressive symptoms are typical of hypothyroidism, connection between postpartum thy-roiditis and PPD has been hypothesized.1,2 Regardless of the etiology, postpartum thyroiditis must be included in the differential diagnosis of a woman presenting with PPD.

Another factor that may contribute to postpartum depres-sion is the decrease of maternal brain DHA and other omega-3 PUFAs during pregnancy. However, brain fatty-acid content has not been studied extensively in humans.10

RISK FACTORSWomen diagnosed with PPD often demonstrate one or more of the following risk factors: history of a depressive episode or MDD; gestational diabetes; multiple gestation; poor marital and social support; and stressful life events, including the stress associated with child care.2,9,13-15 The most signifi cant factors appear to be a history of a depres-sive episode or MDD and occurrence of stressful life events. Low socioeconomic status has also been postulated to be a risk factor for PPD, but research has been inconclusive.16,17

SCREENING AND DIAGNOSISPostpartum screening is recommended by numerous sources, including the American Academy of Pediatrics (AAP)18 and

www.jaapa.com • FEBRUARY 2013 • 26(2) • JAAPA 51

KEY POINTSPostpartum depression is the most common complication of childbearing, occurring in as many as 15% of women during the post- ■

partum period, with some sources suggesting the true incidence may be higher. Thus, all medical providers should know the signs of postpartum depression and the basics of therapy. Patients with postpartum psychosis may develop paranoid, grandiose, or bizarre delusions; mood swings; confused thinking; and ■

disorganized behavior. This is a psychiatric emergency in which the safety of the new mother and her child or children may be jeopardized; for example, a mother may hear voices telling her she should kill her infant. Among the treatment options are pharmacotherapy, including antidepressants and hormone administration, and psychological ■

modalities, including cognitive behavior and interpersonal therapy. Other approaches include exercise, bright light therapy, and acupuncture and massage, as well as prescription of omega-3 polyunsaturated fatty acids.

52 JAAPA • FEBRUARY 2013 • 26(2) • www.jaapa.com

the Academy of Breastfeeding Medicine.19 Legislation has been passed at the national level and by several states to improve screening, treatment, and education for postpartum depres-sion.20 The American College of Obstetrics and Gynecology recommends that both antenatal and postnatal screening for depression be “strongly considered,” although the organization stops short of recommending universal screening at this time.21

Multiple tools exist to screen for PPD. The most commonly used instrument is the Edinburgh Postnatal Depression Scale (EPDS), which is both sensitive and specif-ic in detecting postpartum depression.2 This easily readable questionnaire assesses a patient’s mood over the past week. The 10-question form, which asks respondents to choose from a closed set of possible responses, can be completed and scored in just a few moments. Each response is given a score of 0 to 3. A total score of greater than 12 or any posi-tive response to the item “the thought of harming myself has occurred to me” should prompt a more complete assessment for depression.2 The questionnaire can be accessed online and is most commonly administered at the 6-week postpar-tum visit of the mother or at the 2-month well-child checkup. Translations are available in more than 35 languages.22

Other validated screening tools include the Center for Epidemiologic Studies of Depression instrument (CES-D), the Patient Health Questionnaire (PHQ-9), and the Postpartum Depression Screening Scale (PDSS).23 These instruments are useful for screening, but they should not be used alone to make the diagnosis of PPD. Rather, a positive screen should prompt the clinician to conduct a complete interview to determine if the patient meets criteria for a major depressive episode.

Major depressive disorder, as outlined in the DSM-IV-TR, is characterized by a possible symptom combination of depressed mood, anhedonia, change in weight or appetite, sleep distur-bance, inappropriate guilt, psychomotor disturbance, fatigue, diminished concentration, or thought of death or suicide.6 Five of these symptoms must be present within a 2-week period, and one of the fi ve must be either depressed mood or anhe-donia to make a diagnosis of MDD.6 As previously noted, a designation of symptom onset within 4 weeks following birth allows for a diagnosis of PPD.6 Recent expert opinions suggest that onset within the fi rst 3 months is a more clinically accurate criterion, and that symptom onset of PPD may occur at any point within the fi rst 12 months after childbirth.2

One notable limitation in the defi nition of PPD is that the postpartum onset specifi er in the DSM-IV-TR does

not account for whether or not depressive symptoms were present during time periods prior to pregnancy. In addition, many of the symptoms (sleep deprivation, weight changes, fatigue) may be experienced as part of routine infant care or secondarily from sleep deprivation related to infant care and do not constitute a depressive episode on their own.2 Thus, a detailed history is crucial to carefully differentiate between PPD and a normal postpartum course.

TREATMENTPharmacologic options, psychological therapy, and other therapeutic approaches are available for the treatment of PPD. Counseling, the use of medications, or both are often considered fi rst-line therapy, with other options used as adjuvant therapy.

Psychological or psychosocial options Psychotherapy is an effective treatment for PPD, particularly in women with mild to moderate symptoms. This approach may be a par-ticularly attractive option to women who are breastfeeding and wish to avoid pharmacotherapy because of the effects of certain medications, eg, antidepressants, on themselves and the infant. Psychotherapy may also be used effectively in combination with pharmacotherapy.2 Commonly used psychological modalities include cognitive behavior therapy, in which patients are encouraged to change thought pat-terns and improve coping behaviors, and interpersonal ther-apy, a time-limited, problem-focused modality. Nondirective counseling and enhancement of peer and partner support are strategies also supported by the literature.24

Pharmacologic options While women may be hesitant to use medicines, particularly while nursing, many current medi-cations are effective in the treatment of PPD.24 The choice to use antidepressants may be based in part on the severity of the depression, availability and affordability of psychotherapy, and patient desires.24 Among the pharmacologic options, the selec-tive serotonin reuptake inhibitors (SSRIs) are considered to be the fi rst-line choice for postpartum depression. Fluoxetine, par-oxetine, and sertraline have each been effective in clinical trials.25

Tricyclic antidepressants (TCAs), such as nortriptyline and imipramine, are well-studied and have proven effective in many cases. However, they remain second-line medications because of safety concerns, such as the risk of overdose.25

A third class of treatment is hormonal therapy. Because the postpartum drop in estrogen levels may contribute to the onset of depression, transdermal estradiol has been

CME Postpartum depression

Table 1. Comparison of baby blues, postpartum depression, and postpartum psychosis2,7,23

Baby blues Postpartum depression Postpartum psychosis

Onset 2-3 days postpartum Often 4 weeks; may be up to 1 year

Within 2-4 weeks after delivery

Duration <10 days >2 weeks Variable; often an acute episode of an underlying bipolar disorder

Incidence 80% 10%-15% 1-2/1,000

Suicidal ideation No May be present May be present

tried, with some limited success. However, more data are needed before a clinical recommendation can be made.25

Regardless of which medication is chosen, prescribe the starting dose for 4 days. If that dose is well-tolerated, increase the amount of medication to the lowest dosage in the usual treatment range. Concomitant lifestyle modifi cations should be encouraged. After the depression has resolved, women should be treated for an additional 6 to 9 months before tapering the medication in order to avoid relapse.2

Antidepressants and breastfeeding The use of antidepres-sants is a diffi cult choice for many patients and practitioners when a woman is breastfeeding. The benefi ts of breastfeeding for both the mother and infant are well-understood, and women are strongly encouraged to breastfeed exclusively for the fi rst 6 months of their child’s life by both the AAP and the World Health Organization.26,27 There is little evidence suggesting that breastfeeding while using certain antidepressants is unsafe, but long-term data are limited. Thus, the use of antidepressants in breastfeeding women is a decision to be carefully considered and made by the patient in conjunction with her medical pro-vider. Sertraline and paroxetine may be considered in women who are naive to antidepressant use, as the excretion of these agents in breast milk is very low.28 However, paroxetine has been linked to an increased risk of cardiac defects in the devel-oping fetus and should thus be used with caution in a woman who may become pregnant again while undergoing therapy.28

Continuing use of a medication to which the patient has already responded well is reasonable, unless there is evidence that the medication is unsafe in lactation.2 Safety of medications in lactation may be checked online at LactMed, a peer-reviewed and referenced database of drugs to which breastfeeding moth-ers may be exposed. The database provides such information as the level of each medication secreted in breast milk, the possible effects on infants and on a mother’s ability to produce milk, and other drugs that may be used instead.29

Additional therapeutic options Other modalities exist that may be benefi cial to women with PPD. These include exercise, bright light therapy, and acupuncture and massage.24 While effi -cacy data are limited, all these options are relatively safe and may have other health benefi ts. Electroconvulsive therapy may also be considered for depression that is refractory to other treatments.24

Finally, omega-3 PUFAs, such as eicosapentaenoic acid (EPA) and DHA, have been considered as possible alterna-tive therapy, as these agents are associated with fewer adverse effects for both the mother and child. However, study results have been mixed in terms of the effi cacy of PUFAs in reduc-ing symptoms of postpartum depression.30,31 Further research is needed to determine whether PUFAs can be an effective alternative to antidepressant use in the postpartum period.

SEQUELAE OF PPDThe most concerning factor of PPD is the signifi cant impact of this disorder on both the mother and her child. Mothers with PPD may feel a sense of detachment from their infants. Combined with the widespread cultural assumption that motherhood should be a time of elation in a woman’s life, the

symptoms of PPD may caus e feelings of guilt in a new mother who is not enjoying this period.2 Such feelings often serve to worsen PPD symptoms. In addition, PPD may decrease the quality of the relationship between the mother and her partner.32

Mothers with PPD are more likely to utilize health care resources for somatic complaints than mothers without PPD.33 Whether or not maternal suicide occurs more often in women with MDD during the postpartum period than in women with MDD who are not postpartum remains controversial.2,9,12,32 Regardless, suicide remains a signifi cant concern, and aggres-sive screening for suicidal ideations should be performed.

PPD can have long-lasting effects on the child. Mothers with PPD may spend less time engaged in bonding activities, devel-opmental activities, or even play, and tactile stimulation and soothing of their infants may be decreased.9,30,34 Such behaviors can negatively impact the development of the child’s commu-nication and language skills.12 Addi tionally, maternal PPD can increase the risk of low self-esteem, depression or anxiety dis-orders, or conduct disorder during childhood to adolescence.12 In their role as caregiver, mothers with PPD have been shown to access preventive care, including well-baby visits and routine vaccinations, at a decreased rate while utilizing emergency services for their infants at a higher rate than mothers without PPD.33,34 Poor health, along with sleep and behavior problems of the infant, are often reported by mothers with PPD.12,33 Women with PPD are less likely to breastfeed and to ensure routine safety measures for their infants.9,12,34 Postpartum depressive mothers have also shown more aggressive behavior toward the infant or fear of being alone with the baby.2,34 In cases of severe PPD, aggressive behavior directed toward the infant may result in abuse or infanticide,12 as well as serving as an additional cause for the previously discussed psychiatric disorders observed in children of depressed mothers.

CONCLUSIONPostpartum depression can make the fi rst months of an infant’s life challenging for both the mother and her newborn child. With careful screening, diagnosis, and treatment, however, PAs can help new parents through this transition to ensure the healthiest family possible. JAAPA

The authors are affi liated with the Department of Physician Assistant Edu-cation, St. Louis University, St. Louis, Missouri. Genevieve DelRosario is an assistant professor and clinical director of the PA program, Caroline Chang is an instructor, and Elizabeth Lee is a student.

No relationships to disclose.

www.jaapa.com • FEBRUARY 2013 • 26(2) • JAAPA 53

SEE THE ONLINE VERSION OF THIS ARTICLE TO LINK TO The Edinburgh Postnatal Depression Scalehttp://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf

LactMedhttp://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

54 JAAPA • FEBRUARY 2013 • 26(2) • www.jaapa.com

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among low-income mothers. JAMA. 2009;301(8):842-847. 14. Choi Y, Bishai D, Minkovitz CS. Multiple births are a risk factor for postpartum maternal depres-

sive symptoms. Pediatrics. 2009;123(4):1147-1154. 15. O’Hara MW. Postpartum depression: what we know. J Clin Psychol. 2009;65(12):1258-1269. 16. Tucker JN, Grzywacz JG, Leng I, et al. Return to work, economic hardship, and women’s postpar-

tum health. Women Health. 2010;50(7):618-638. 17. Eastwood JG, Phung H, Barnett B. Postnatal depression and socio-demographic risk: factors

associated with Edinburgh Depression Scale scores in a metropolitan area of New South Wales, Australia. Aust N Z J Psychiatry. 2011;45(12):1040-1046.

18. Earls MF, Committee on Psychosocial Aspects of Child and Family Health. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032-1039.

19. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #18: use of antidepressants in nursing mothers. Breastfeed Med. 2008;3(1):44-52.

20. National Institute for Health Care Management. Identifying and treating maternal depression: strategies and considerations for health plans. http://nihcm.org/pdf/FINAL_MaternalDepression6-7.pdf. Published June 2010. Accessed January 9, 2013.

21. American College of Obstetricians and Gynecologists. Committee opinion no. 453: screening for depression during and after pregnancy. Obstet Gynecol. 2010;115(2 pt 1):394-395.

22. Department of Health, Government of Western Australia. Edinburgh Postnatal Depression Scale (EPDS): Translated versions—validated. Perth, Western Australia: State Perinatal Mental Health Reference Group. http://www.folkhalsoguiden.se/upload/Psykisk%20H%C3%A4lsa/Edinburgh%20Depression%20Scale%20Translated%20Government%20of%20Western%20Australia%20Department%20of%20Health.pdf. Published 2006. Accessed January 9, 2013.

23. Sit DK, Wisner KL. The identifi cation of postpartum depression. Clin Obstet Gynecol. 2009;52(3):456-468.

24. Fitelson E, Kim S, Baker AS, Leight K. Treatment of postpartum depression: clinical, psychologi-cal and pharmacological options. Int J Womens Health. 2010;3:1-14.

25. di Scalea TL, Wisner KL. Pharmacotherapy of postpartum depression. Expert Opin Pharmacother. 2009;10(16):2593-2607.

26. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.

27. World Health Organization. Global strategy for infant and young child feeding. Geneva, Switzerland: World Health Organization and UNICEF. http://whqlibdoc.who.int/publications/2003/9241562218.pdf. Published 2003. Accessed January 9, 2013.

28. Berle JO, Spigset O. Antidepressant use during breastfeeding. Curr Womens Health Rev. 2011;7(1):28-34.29. United States National Library of Medicine. Drug and lactation database (LactMed). http://toxnet.

nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. Updated December 21, 2011. Accessed January 9, 2013. 30. Su KP, Huang SY, Chiu TH, et al. Omega-3 fatty acids for major depressive disorder during

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33. Darcy JM, Grzywacz JG, Stephens RL, et al. Maternal depressive symptomatology: 16-month follow-up of infant and maternal health-related quality of life. J Am Board Fam Med. 2011;24(3):249-257.

34. Field T. Postpartum depression effects on early interactions, parenting, and safety practices: a review. Infant Behav Dev. 2010;33(1):1-6.

CME Postpartum depression

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