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In Postpartum Depression, Early Treatment Is Key

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In Postpartum Depression, Early Treatment Is Key In postpartum depression, early treatment is key The tragedy of Andrea Yates, the Texas mother convicted of drowning her 5 children, raises questions about the role of physicians in identifying and treating women at risk for severe postpartum depression. In most cases, Ob/Gyns are the first line of defense. By SHAILA MISRI, MD, and XANTHOULA KOSTARAS n the postpartum period, between 12% Although the fourth edition of the and 16% of women experience a major Diagnostic and Statistical Manual of Mental depressive episode that can Disorders (DSM-IV) states that the I Shaila Misri, MD have severe and long-lasting onset of PPD occurs within 4 consequences for both moth- weeks of giving birth,5 our clinical er and infant.1,2 If left untreat- experience indicates that it can ed, postpartum depression occur up to 1 year after birth. The (PPD) can impair maternal- essential feature of a major infant bonding and hinder the depressive disorder, according to child’s cognitive and emo- the DSM-IV, is “a clinical course tional development. that is characterized by one or This article is based on our Many women fail to more Major Depressive Episodes” experience caring for women report depressive (Table 2). with PPD, and aims to help the PPD often is associated with Ob/Gyn detect and diagnose the symptoms during comorbid anxiety disorders, disorder more quickly and make their routine which manifest in many ways. psychiatric or psychotherapeutic Panic attacks frequently are the referrals when appropriate. postpartum visit. first indication of existing or impending depression. A small Risk factors percentage of women will experi- Key risk factors, such as a his- ence intrusive obsessional tory of PPD or depression, have been identi- thoughts of harming their infants. fied as predictors of PPD (Table 1).3,4 Screening and diagnosis Many women fail to report depressive Dr. Misri is a professor of psychiatry and OBG at symptoms to their obstetricians during the the University of British Columbia and director of routine postpartum visit. A recent study of the Reproductive Mental Health Program at St. 391 outpatients in an obstetric practice Paul’s Hospital and British Columbia Women’s demonstrates the value of using a screening Hospital, both in Vancouver, Canada. Ms. instrument to identify possible PPD cases at Kostaras is a research assistant in the this time. When the women were screened Reproductive Mental Health Program at St. Paul’s with the standardized Edinburgh Postnatal Hospital in Vancouver. Depression Scale (EPDS), the rate of detec- continued on page 53 50 OBG MANAGEMENT • JUNE 2002 tion of PPD was 35.4%, compared with a TABLE 1 spontaneous detection rate of 6.3%.6 Risk factors for postpartum The EPDS, shown on page 65, is a 10-item depression self-report questionnaire developed by Cox Major factors and colleagues and used specifically to •History of PPD 7 detect PPD. A minimum score of 12 or 13 or •History of depression higher warrants a diagnosis of PPD. The •Family history of depression, especially PPD instrument can be used as a screening tool at •Depression during pregnancy 6 to 8 weeks postpartum and can be repeat- Contributing factors ed over several visits to track symptoms. It •Poor social support has been validated, computerized, and trans- •Adverse life events lated into more than 12 languages and can be •Marital instability copied and used free of charge. •Younger maternal age (14 to 18 years) A new screening tool, the Postpartum •Infants with health problems or perceived poor Depression Screening Scale (PDSS), was temperaments recently developed and validated by Beck and •Unwanted or unplanned pregnancy colleagues to help clinicians identify and •Being a victim of violence or abuse respond to PPD as early as possible.8 •Low self-esteem Depressive symptoms are rated on a 5-point •Low socioeconomic status scale, and the total score is used to determine the overall severity of depressive symptoms. DSM-IV criteria for a major TABLE 2 Higher PDSS scores reflect more severe symp- depressive episode toms and indicate that the patient should be referred for psychiatric evaluation. The PDSS A. Five or more of the following symptoms must is published by Western Psychological be present daily or almost daily for at least 2 Services (www.wpspublish.com). consecutive weeks: 1. Depressed mood* Management guidelines 2. Loss of interest or pleasure* Based on our experience and the available 3. Significant increase or decrease in appetite evidence, we offer these recommendations 4. Insomnia or hypersomnia to Ob/Gyns managing patients with PPD: 5. Psychomotor agitation or retardation 1. During the initial postpartum assessment, 6. Fatigue or loss of energy use screening tools such as the EPDS or the 7. Feelings of worthlessness or guilt PDSS to identify symptom patterns and assist 8. Diminished concentration with diagnosis. 9. Recurrent thoughts of suicide or death 2. Give the patient educational materials B. The symptoms do not meet the criteria for other about PPD and her treatment options to help psychiatric conditions. her make informed decisions. Reading lists, C. The symptoms cause significant impairment in appropriate research articles, lists of local functioning at work, school, and social activities. resources, and Web sites can increase her D. The symptoms are not caused directly by a sub- awareness of PPD and drive home the stance or general medical condition. importance of seeking and complying with E. The symptoms are not caused by bereavement treatment. When appropriate (e.g., in cases after the loss of a loved one. of moderate to severe PPD), refer the patient *At least one of the 5 symptoms must be #1 or #2. for counseling and encourage her to include SOURCE: Adapted from Diagnostic and Statistical Manual of Mental Disorders. 4th ed [text revision]. Washington, DC: American Psychiatric Association; 2000. her partner, family members, and/or other social supports. 3. If pharmacotherapy is to be prescribed, 4. Outline a treatment plan with the patient discuss the medication’s benefits and potential and her partner. This should include 6 weeks risks for both mother and infant—over the short of treatment during the acute phase, as well and long term—in an honest and open fashion. as maintenance and long-term therapy. continued on page 54 JUNE 2002 • OBG MANAGEMENT 53 During the acute phase, the mood of the However, if the depression worsens at any patient should be carefully monitored on a time, treatment with the appropriate medica- weekly basis. It may be necessary to include tion should be made available. Among the a psychiatrist or mental health- options are cognitive-behavioral care worker during this phase. Interpersonal therapy therapy, interpersonal therapy, If applicable, discuss the group therapy, family and/or 5. helps decrease planning of future pregnancies marital therapy, supportive psy- while the woman is still on depressive symptoms chotherapy, and peer-support pharmacotherapy—and include groups. Psychosocial therapies in women with her partner, if at all possible. also should be used as adjuncts Women who have experienced moderate PPD. to pharmacotherapy. repeated episodes of depres- Cognitive-behavioral therapy. A pre- sion almost always relapse liminary study examining short- when they discontinue an anti- term cognitive-behavioral coun- depressant during pregnancy. seling for women with PPD reported that Psychosocial therapies are the first line of patients who participated in 6 sessions treatment for mild to moderate PPD and are improved as much as women receiving flu- useful adjuncts to pharmacotherapy. When oxetine alone. Both groups demonstrated psychotropic medications are indicated for greatly improved functioning when com- moderate to severe symptoms, consider the pared with controls.9 potential risk of exposing the breastfeeding Interpersonal therapy. During pregnancy and infant to the drugs. the postpartum period, this therapy focuses on role transitions and the acquisition of Mild to moderate PPD skills applicable to motherhood. The results OBG patients diagnosed with this level of of preliminary studies have been encourag- PPD should be referred for counseling, par- ing.10 For example, a recent controlled trial of ticularly if they refuse pharmacotherapy. 99 women found that interpersonal therapy continued on page 59 SSRI drug therapy for postpartum depression TABLE 3 Starting daily Maximum daily Medication dose (mg) dose (mg) Precautions Fluoxetine 10 80 Very long half-life of active metabolite may lead to accumulation in infants. Inform parents of possible side effects. Sertraline 25 300 Benign neonatal sleep myoclonus has been documented in 1 case of sertraline exposure during breastfeeding. Inform parents of possible side effects. Paroxetine 10 60 No adverse effects reported. Fluvoxamine 50 300 Data limited Citalopram 10 60 Data limited 54 OBG MANAGEMENT • JUNE 2002 Related Resources Publications: ■ Misri S. Shouldn’t I Be Happy? Emotional Problems of Pregnant and Postpartum Women. New York, NY: Free Press; 1995. ■ Sichel D, Driscoll JW. Women’s Moods: What Every Woman Must Know About Hormones, the Brain, and Emotional Health. New York, NY: William Morrow; 1999. Support groups: ■ Depression After Delivery, Inc. www.depressionafterdelivery.com or 1-800-944-4773 (4PPD) What ■ Postpartum Support International. www.postpartum.net begins ■ Pacific Postpartum Support Society. www.postpartum.org with “O” helps decrease depressive symptoms and promotes social adjustment in women with and moderate PPD.11 Group therapy. One of the most valuable ben- ends efits of group therapy in the treatment of PPD is that it may help women who are feel- ing socially isolated increase their support with you? networks. Family and marital therapy. The roles of the part- ner and family are critical in the treatment of women with mood and anxiety disorders during pregnancy or the postpartum period. A recent study found women with PPD recover more rapidly when the partner is supportive.12 Supportive psychotherapy involves offer- ing patients and their families support, reas- surance, and education; it augments other psychosocial interventions and/or pharma- cotherapy.
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