Postpartum depression (PPD) affects 1 of every 10 women worldwide.1 Its consequences are borne not only by the mother but by the entire family.2 Low-income women are at particularly high risk. They often receive less prenatal and postpartum services, including screening and intervention for PPD.3
Prevalence and Etiology
PPD occurs in 10% to 15% of new mothers.4 Providers may find it challenging to distinguish between PPD and the common "baby blues" experienced after birth. Symptom severity and duration can differentiate between them. The baby blues typically consists of feelings of emotional instability, anxiety and irritability within the first few days postpartum, lasting only about 2 weeks. These symptoms are reported in 26% to 86% of postpartum women.5 In contrast, PPD is characterized by feelings of depressed mood, worthlessness, anhedonia or extreme guilt. These symptoms usually occur daily and continue for at least 2 weeks.5 PPD usually begins within 6 weeks of delivery and can last 2 weeks to several years.
PPD should be distinguished from postpartum psychosis. This is characterized by psychotic features such as disorganization, hallucinations and delusions.5
To develop a clinical understanding of PPD, it is valuable to review the physical and hormonal changes that occur after birth. In a healthy pregnancy, a woman's estrogen and progesterone increase dramatically to sustain the uterine lining and placenta sufficiency.6 The increase in estrogen stimulates increases in thyroid hormones T3 and T4. Within 48 hours after delivery, these hormones rapidly decrease, which can affect a woman's emotional state. Beta-endorphin, human chorionic gonadotropin, and cortisol all increase during pregnancy, peak during birth, and then decline during the postpartum phase.7 Other hormones that must be taken into account include prolactin and oxytocin, which are impacted by a mother's choice to breastfeed.
Both hormonal and psychosocial factors cause and exacerbate PPD.7,8 Recent research suggests that most women who develop PPD are predisposed and present with certain risk factors.6 The presence of any of the following risk factors increase the likelihood that the new mother will experience symptoms of PPD:7,9
• personal history of PPD or depression
• lack of social support
• annual income less than $25,000
• stress about child care
• single marital status
• age younger than 19
• race and ethnicity other than white
• recent stressful life events.
A meta-analysis found that women with socioeconomic disadvantage face an increased risk for a postpartum mental health disorder.10 Pregnant women who scored higher on the Beck Depression Scale were more likely than their lower-scoring counterparts to identify cost, lack of insurance, lack of treatment and transportation challenges as the most significant barriers to treatment.11
Routine screening for risk factors and symptoms associated with PPD should be considered for all women during the prenatal and postpartum periods.1,12
Providers can implement PPD screening into routine postpartum visits or at the 2-month well child visit. Risk factors should be considered throughout pregnancy.
Despite its importance, screening is often neglected during the postpartum visit because of time constraints and absence of clear diagnostic guidelines. The same screening tools are often used for PPD and major depression. However, commonly used depression screening tools, such as the Beck Depression Inventory, underdiagnose PPD.7 Women in the postpartum period have unique physiologic and psychologic complaints, such as poor body image and fatigue from lack of sleep, which can skew results.
The Centers for Disease Control and Prevention recommends using the highly sensitive Pregnancy Risk Assessment Monitoring System survey.4 It consists of two questions: "Since your baby was born, how often have you felt down, depressed or hopeless?" and, "Since your baby was born, how often have you had little interest or little pleasure in doing things?" Response options are "always," "often," "sometimes," "rarely" and "never." Women who respond with "always" or "often" to either question warrant evaluation and should complete a depression survey such as the Edinburgh Postnatal Depression Scale (EPDS; http://fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf).13
Administering the 10-question EPDS to all women at 6 weeks postpartum can increase the rate of PPD diagnosis.12 Both the EPDS and the Patient Health Questionnaire (http://www.integration.samhsa.gov/images/red/PHQ%20-%20Questions.pdf) take less than 5 minutes to administer and are highly specific and sensitive.11,13,14 The American College of Obstetricians and Gynecologists also recommends the Postpartum Depression Screening Scale, but this 35-question survey can take up to 10 minutes to administer.12
Another important consideration in screening for PPD is the negative stigma associated with mental health problems. It is common for women to fear they will be labeled as unfit to parent if they are diagnosed with PPD.15 To overcome these fears, providers should explain that they are advocates for patients. Specific strategies include educating about the prevalence of PPD and validating the normalcy of PPD symptoms. Focus on the fact that with appropriate diagnosis and treatment, symptoms usually improve or completely resolve.
Beyond diagnosis, low-income women are challenged when it comes to treatment because they are significantly less likely to be treated for PPD if they don't have health insurance.16,17
Treatment must be multifaceted and consider all members of the family. Pay attention to family safety and abilities of the caregiver. After diagnosis, screen the mother for suicidal and homicidal thoughts to ensure that she is safe to leave the clinic. Around 60% of women experiencing PPD report obsessive thoughts focused on aggression toward the infant.18 Women often experience intermittent ideation and may not report feeling suicidal at the time of visit.18 A question to assess for this is, "Do you ever wish you would fall asleep and not wake up?"
Two goals are primary when offering assistance to women and families affected by PPD. First, create a safe, supportive and trusting environment for the patient and family to express concerns, report symptoms and accurately evaluate the mother's current capabilities as a caretaker. Next, develop and facilitate a treatment plan that meets the patient's particular needs.
A multifaceted treatment approach is recommended. It should include health promotion, enhancement of social support, crisis planning, counseling and pharmaceutical agents. Treatment should begin with nonpharmacologic interventions. These are effective for mild to moderate PPD symptoms and are usually better received by postpartum women than medications.18,19 It is important to access treatment options appropriate for the specific community setting as well as for the patient's financial capabilities.
Health promotion is a new and promising area of treatment for PPD in low-income women. One study showed that low-income women who received nutrition education and motivational counseling for 15 months were significantly less likely to experience PPD than controls.20
Social support is associated with increased maternal confidence and mother-infant bonding.2 A cost-effective option for social support is maternal support groups. Improved outcomes have been documented in communities with mental health professionals, nurses and peers to offer postpartum support.15
Another option for enhancing social support is to develop crisis prevention or social support plans for new mothers prior to delivery. This plan is a list of names and phone numbers for people who can be available to the new mother. Such plans allow women to consider their own social network and resources prior to any PPD symptoms.
It is also important to determine when counseling referral is appropriate. This will depend on available community resources and wait times. The typical wait time between referral and an actual counseling session varies. Therefore, counseling is only recommended if the patient is able to obtain services within 1 to 3 weeks and is not a danger to herself or her baby. Explain how to obtain quicker psychiatric services and when those are necessary.
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When the needs of a patient are acute, immediate action may be required. Every practice should create an emergency plan that contains protocols as well as contact information for psychiatric professionals who can provide on-call evaluations. The plan should include inpatient facilities and their points of contact. Collaboration and planning with mental health providers is key. In rural communities, consider creating a protocol for telecommunication with a psychiatrist who can better evaluate acuity and offer recommendations.
Treatment should target the mother's symptoms as well as the mother-infant relationship.17 Suggesting a meeting with a lactation consultant or offering to observe a mother nurse her infant can help promote that bond. It can also help reassure the patient that despite her current feelings, she can still be a capable and caring mother. Table 1 shows recommendations for promoting mother-infant bonding.
Medications can offer therapeutic benefit for patients with moderate to severe PPD. A thorough history and physical should be completed to determine which antidepressant or anti-anxiety medication is appropriate and when it should be implemented. For high-risk women, some experts suggest beginning antidepressant medication in the third trimester or immediately after delivery.17 Women who use pharmacologic interventions for PPD usually experience improvement quickly and treatment discontinuation can be considered after 6 months.19 Inform the patient that antidepressants typically take 3 to 6 weeks to demonstrate effectiveness.
Appropriate pharmacologic therapy for breastfeeding women includes selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (Table 2).16 No specific recommendations have been made as to a single most effective agent. The use of estrogen therapy is being considered as an alternative, but more research is needed.16
Complete a risk-benefit analysis for each patient, but the consensus is that the benefits of treating the mother outweigh risks to the breastfed infant.4
1. World Health Organization. Maternal Mental Health & Child Health and Development. http://www.who.int/mental_health/prevention/suicide/MaternalMH/en
2. Hutto HF, et al. Pospartum depression among white, African American, and Hisupic low income mothers in rural southeastern North Carolina. J Community Health Nurs. 2011;28(1):41-53.
3. Beck L, et al. Prevalence of selected maternal behaviors and experiences, pregnancy risk assessment monitoring system (PRAMS). MMWR Surveill Summ. 2002;51(2):1-27.
4. Centers for Disease Control. Prevalence of self-reported postpartum depressive symptoms. http://www.cdc.gov/MMWR/preview/mmwrhtml/mm5714a1.htm
5. Epperson CN. Postpartum major depression: detection and treatment. Am Fam Physician. 1999;59(8):2247-2254.
6. Hendrick V, et al. Hormonal changes in the postpartum and implications for postpartum depression. Psychosomatics. 1998;39(2):93-101.
7. Stewart D, et al. Postpartum depression: Literature review of risk factors and interventions. http://www.who.int/mental_health/prevention/suicide/lit_review_postpartum_depression.pdf
8. Schanie CL, et al. Analysis of popular press articles concerning postpartum depression: 1998-2006. Issues Ment Health Nurs. 2008;29(11):1200-1216.
9. Agency for Healthcare Research and Quality. Efficacy and safety of screening for postpartum depression. http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=997&pageaction=displayproduct
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12. American College of Obstetricians & Gynecologists. Committee Opinion: Screening for postpartum depression. http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Screening_for_Depression_During_and_After_Pregnancy
13. Cox JL, et al. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Brit J Psychiatry. 1987;150(6):782-786.
14. Kroenke K, et al. The PHQ-9: validity of a brief depression severity measure. Gen Intern Med. 2001;16(9):606-613.
15. 12. Georgiopoulos AM, et al. Routine screening for postpartum depression. J Fam Pract. 2001;50(2):117-122.
16. Miles S. Winning the battle: A review of postnatal depression. Brit J Midwifery. 2011;19(4):221-227.
17. Farr SL, et al. Mental health and access to services among US women of reproductive age. Am J Obstet Gynecol. 2010;203(6):542-551.
18. Howard L. Postnatal depression. Am Fam Physician. 2005;72(7):1294-1296.
19. Hirst KP, Moutleir MD. Postpartum major depression. Am Fam Physician. 2010;82(8):926-933.
20. Thompson KS, Fox JE. Post-partum depression: a comprehensive approach to evaluation and treatment. Ment Health Fam Med. 2010;7(4):249-257.
21. Surkan PJ, et al. Impact of health promotion intervention on maternal depressive symptoms at 15 months postpartum. Matern Child Health J. 2012;16(1):139-148.
22. Steinberg SI, Bellavance F. Characteristics and treatment of women with antenatal and postpartum depression. Int J Psychiatry Med. 1999;29(2):209-233.
Kathryn Weinberg is a family nurse practitioner at Seattle Pain Center in Seattle. She has completed a disclosure form and reports no relationships related to this article.