Postpartum depression in a primary-care setting

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Postpartum depression in a primary-care setting
Postpartum depression in a primary-care setting

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In 2001, Andrea Yates stunned the world when she methodically drowned her five children in the bathtub while suffering from postpartum psychosis, the most severe of the three postpartum clinical syndromes mothers may experience.

The other two clinical syndromes are postpartum blues — the mildest syndrome, experienced by more than half of mothers during the first few weeks after giving birth — and postpartum depression (PPD), a type of major depression that is experienced by 10% to 20% of mothers.1

While the willingness of such high-profile women as Gwyneth Paltrow, Marie Osmond and Brooke Shields to speak openly about their struggles with PPD has added further to public awareness of this condition, many cases still go undetected and untreated. Many women are reluctant to discuss their symptoms, and practitioners may not be attuned to the possibility that a mother may be experiencing PPD.2



The discrepancy between a mother's expectations of what life will be like following delivery and the negative thoughts and feelings she may actually experience can lead to guilt, confusion, shame and reluctance to reveal her distress to her clinician. Moreover, practitioners may not include screening questions or instruments as a part of their routine assessment process.

Description of postpartum syndromes

Of the three postpartum conditions, the mildest is postpartum blues. Such symptoms as unstable mood, weepiness, sadness, lack of concentration, anxiety and irritability are attributed to changes in hormones and stress level. Symptoms usually peak around five days after giving birth and resolve within two weeks without intervention.2 However, for women with a history of depression, postpartum blues may signal relapse.3

The most severe of the three postpartum disorders is postpartum psychosis, which affects one in 500 mothers and typically appears rapidly during the first month following delivery.4 Symptoms include confusion, hallucinations, delusions, depressed mood, mania, mood lability and disorganized thinking. Postpartum psychosis is often a manifestation of bipolar disorder and usually requires hospitalization because of the mother's level of impairment and risk to both self and child.5

PPD is more severe but less prevalent than postpartum blues and less severe but more prevalent than postpartum psychosis. PPD is actually a form of major depression.6 What distinguishes PPD from other variants of major depression is that PPD occurs during the postpartum period.

The symptoms of PPD are basically the same as those of other manifestations of major depression: depressed mood or sadness, decreased interest or pleasure, changes in appetite and sleeping, crying spells, suicidal thoughts, feelings of guilt or worthlessness, difficulty concentrating and fatigue. In addition, depressed mothers may exhibit emotional lability and excessive concern with the infant.6

Symptoms need to be present for at least two weeks and occur during the postpartum period, which is considered to last up to one year following childbirth. Many of the symptoms of PPD can also result from such medical conditions as anemia and hypothyroidism.

Depression occurs twice as often in women as in men, but the prevalence of depression in postpartum women (10% to 20%) is no greater than that of other women. Up to 10% of new fathers, a group that is often overlooked, may also experience PPD.7

Practitioners often miss the diagnosis of PPD because they attribute many of the neurovegetative symptoms of depression (i.e., sleep and appetite changes, lack of energy and decreased enjoyment) to the normal changes of pregnancy and the postpartum period.3 However, failure to detect PPD can have serious consequences for both mother and child.

For example, while women suffering from PPD are less likely to attempt suicide than other depressed women, when they do attempt, they use more lethal methods, making suicide the leading cause of postnatal maternal death.4

PPD in mothers is also linked to a variety of problems in their offspring, including the following: decreased weight gain, health concerns, and nighttime awakenings in infants;8 cognitive problems, emotional maladjustment, and behavioral inhibition in children;4,9 and depression and anxiety in adolescents.10

The potentially serious consequences of PPD for mother and child underscore the importance of improved detection, prevention and effective treatment of this condition in primary-care settings.

Causal and risk factors


As with other psychological disorders, biological and psychosocial factors converge to influence the development of  PPD. Biological influences include genetics, hormonal changes, neurotransmitter systems and abnormalities in the hypothalamic-pituitary-adrenal axis (HPA).1

A history of prior depression places a mother at greater risk for PPD, and parents and siblings of depressed women are at least twice as likely to develop depression as the general population.3 Recent studies have also identified genes associated with both estrogen and serotonin activity that have been implicated in PPD.1,11

Hormonal changes loom large as a likely causal factor for PPD. While levels of estrogen and progesterone rise during pregnancy, these levels rapidly decrease within 48 hours after giving birth. Because of the interaction between reproductive hormones and neurotransmitter systems — especially serotonin — the sudden reduction in hormone levels is thought to contribute to a decrease in activity of neurotransmitters that regulate mood.1

A recent study found that non-depressed women with higher levels of the neurotransmitter beta-endorphin throughout pregnancy were at increased risk of developing PPD, most likely because of the rapid reduction in beta-endorphin levels after delivery.12 Replication of these findings could lead to the eventual use of a blood draw during pregnancy to help identify women at risk of developing PPD. Finally, HPA abnormalities associated with PPD include elevated corticotropin-releasing hormone levels and a greater cortisol response to stress during pregnancy in women who later develop PPD.1

Psychosocial factors that have been found to place mothers at increased risk for PPD include depression and anxiety during pregnancy, postpartum blues, history of major depressive disorder, high stress level and lack of spousal and family support.2

An examination of high-anxiety and depression in women and men from early pregnancy to three months postpartum found that women were more anxious than men at the third trimester of pregnancy and at childbirth and more depressed than men in all phases of pregnancy and at childbirth.7 Women with a history of depression are more than twice as likely to develop PPD, and at least half of mothers who experience PPD will experience a recurrence associated with future births.1

These findings underscore the importance of inquiring about a history of depression and anxiety and identifying stressors and sources of support early on so that at-risk mothers can be identified and additional measures of support can be provided.

A promising area of recent research involves investigation of the relationship between depression, nutrition and parenting in new mothers. A relationship between low iron levels, depressive symptomatology and authoritarian parenting style in breastfeeding mothers at three months postpartum has been demonstrated.13 Authoritarian parents are high in control and low in support and therefore are less nurturing with their children.

It is hypothesized that insufficient nutrition may adversely affect the biosynthesis and activation of neurotransmitters regulating mood and result in decreased energy to cope with psychosocial stressors, both of which could place mothers at increased risk for depression. Moreover, the authoritarian parenting style may lead to insecure infant attachment and negative mother-child interactions, which in turn could contribute further to depression in the mother.14

Detection


Primary-care practitioners (PCPs) often fail to address the possibility of depression with their pregnant and postnatal patients.4 However, clinic visits by pregnant women and subsequent postnatal and well-baby visits provide practitioners with ideal opportunities to screen for depression and provide information and support. In an effort to assist practitioners with this task, two National Institute of Mental Health-supported online training programs are now available.15,16    

The most widely used, validated screening instrument for the detection of postpartum (and antepartum) depression is the Edinburgh Postnatal Depression Scale (EPDS).17,18 This 10-item scale relies less on somatic questions than other depression screening instruments (i.e., the Beck Depression Inventory) because the EPDS was specifically developed for assessing depression in postpartum women.19 The scale is readily available online and can be used free of charge as long as users respect the copyright by quoting author names, title, and source in all reproduced copies.

Women who complete the EPDS are asked to rate each question on a scale of 0 to 3, describing how they have felt over the past seven days. Scores can range from 0 to 30; cut-off scores of 10/11 have been suggested for possible depression and 12/13 for probable depression in postpartum women, and a cut-off score of 14/15 has been suggested for probable depression in pregnant women.18

Another approach to the detection of PPD is the use of case-finding questions. A recent study examined the diagnostic accuracy of the use of the following questions with both pregnant and postpartum women:20
  • “During the past month, have you often been bothered by feeling down, depressed, or hopeless?”
  • “During the past month, have you often been bothered by having little interest or pleasure in doing things?”
  • A third question should be considered if the woman answers “Yes” to either of the initial questions: “Is this something you feel you need or want help with?”
The authors evaluated self-reported responses to the first two questions against standard diagnostic criteria for major depressive disorder. Negative responses to both of the first two case-finding questions were accurate for ruling out depression, while positive responses to the third question improved accuracy for ruling in depression.

Both the EPDS and case-finding questions are useful tools available to PCPs.

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