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POSTPARTUM DEPRESSION
BEYOND THE BLUES
INCIDENCE OF DEPRESSION
Each year, 15% to 20% of adults in the United States experience a major depression
The incidence among women is twice that of men and peaks between 18 to 44 years of age - the childbearing years
DEPRESSION IN WOMEN
Women are at increased risk of mood disorders during periods of hormonal fluctuation- premenstrual postpartum perimenopausal
THE RANGE OF POST-DELIVERY MOOD DISORDERS50% to 80% of women experience transient
“baby blues” within the first two weeks following delivery
0.1% to 0.2% of women experience postpartum psychosis usually within the first 4 weeks following delivery
POSTPARTUM DEPRESSION
6.8% to 16.5% of women experience postpartum depression (PPD) also known as postpartum major depression (PMD)
Onset can be as early as 24 hours or as late as several months following delivery
SYMPTOMS OF POSTPARTUM DEPRESSIONHopelessness Loss of pleasure in activities
Helplessness Mood changes
Persistent sadness Inability to adjust to role ofmotherhood
Irritability Inability to concentrate
Low self-esteem Sleep /appetite disturbances
RANGE OF SYMPTOMS
Symptoms range- from mild dysphoria to suicidal ideation to psychotic depression
DURATION OF SYMPTOMS
Untreated, symptoms can last:
several months
into the second year postpartum
THE ETIOLOGY OF POSTPARTUM DEPRESSION
Various theories based in physiological changes have been postulated: hormonal excesses or deficiencies of estrogen,
progesterone, prolactin, thyroxine, tryptophan, among others
ETIOLOGY OF POSTPARTUM DEPRESSION
Other theories cite numerous psychosocial factors associated with PMD: marital conflict child-care difficulties (feeding, sleeping, health
problems) perception by mother of an infant with a
difficult temperament history of family or personal depression
Higher rates of depression were noted among women who:Had less than a high school education
Reported being abused before or during pregnancy
Were less than 19 years old Had 0 to 1 person as a source of social support
Resided in a household with an income <$15,000
Were not married
Experienced an unintended pregnancy
Reported 6 to 18 stresses during pregnancy (sick family member, divorce, etc.)
THE IMPACT OF POSTPARTUM DEPRESSION
LONG TERM CONSEQUENCES OF PMD
Negative impact on the infant ‘s social, emotional and cognitive development
2 month old infants of mothers with PMD had decreased cognitive ability and expressed more negative emotions during testing
LONG TERM CONSEQUENCES OF PMDBabies of mothers
with PMD were perceived by their mothers as more difficult to care for and more bothersome.
POSTPARTUM DEPRESSION & MATERNAL MORTALITY
In recent years, there have been two maternal deaths due to suicide by women within one year of giving birth.
Neither woman had been screened for postpartum depression
RISK FACTORS FOR PMD-Family history of mooddisorder
-Child-care difficulties:feeding, sleeping, health
-Client history of mooddisorder prior to pregnancy
-Marital conflict
-Anxiety/depression duringpregnancy
-Stressful life events
-Previous postpartumdepression
-Poor social support
-Baby blues following currentdelivery
INTERVENTIONS
SCREENING FOR PMD
SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY:
Be unable to recognize she is depressed
SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY:
Believe her symptoms are “normal” for new moms
SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY:
Fear being labeled a “bad mother” if she admits her maternal experience does not meet society’s picture of bliss
SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY:
Feel she is going crazy and fears her baby will be taken from her
WHEN TO SCREEN FOR PMDAt preconception visitDuring prenatal intake & subsequent visitsDuring postpartum examsDuring infant’s WCC & WIC visitsWhen infant is seen for sick care or in ERAt early intervention home visitsAt family planning visits during the first year
postpartumAt mother’s visits for routine episodic care
SCREENING TOOLS
There are several tools available: Edinburgh Postnatal Depression Scale (EPDS) The Mills Depression & Anxiety Checklist The Center for Epidemiological Studies
Depression Scale (CES-D) Others, often on various websites for mental
health
A WORD ABOUT SCREENING TOOLS!
Be familiar with the tool - its validity and limitations
Have a referral network available for women screening positive
Document the screening and any referrals made
Follow-up with your client to assure that she received needed assistance
EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS)
Designed for home or outpatient useConsists of 10 questionsCan be completed in approx. 5 minutesReviews feelings the previous 7 daysScored 0-3 depending on symptom severity Depending on study, cut off is 13 - 9 points
TREATMENT
1. Educate the woman and her support system regarding the diagnosis of
postpartum depression.
TREATMENT OPTIONS
Pharmacological intervention
Counseling, individual and/or group
Support groups
PHARMACOLOGICAL INTERVENTION
Use of tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) may be indicated for both non-nursing and nursing mothers
Have low incidence of infant toxicity and adverse effects during breastfeeding*
Decisions regarding use while breastfeeding must be on a case by case basis
OTHER CONSIDERATIONS:
Provider must be familiar with agents and the hepatic function of mother and infant
Client must be informed of risks/benefits of treatment Vs. no treatment for herself and her infant unknown impact of long-term use of
medications on neurodevelopment of infant
Other Considerations - Cont.If the woman chooses to breastfeed while on
psychotropics, she should work collaboratively with a psychiatrist and her pediatrician
If the infant experiences insomnia or other behavior changes, his serum should be assayed for the presence of medication
Document all discussions regarding treatment in the client’s chart
COUNSELINGKnow referral sources in your locale,
especially those that: accept Medicaid utilize a sliding fee will develop a payment plan with the client offer free counseling
Be familiar with indigent drug programs available through various pharmaceutical manufacturers
Counseling - Cont.
Any woman with symptoms of psychosis or with serious suicidal/homicidal ideation should be referred for emergency psychiatric evaluation
SUPPORT GROUPS
Numerous postpartum support groups are available. Contact:
Local mental health agenciesHospitalsWebsites