A review of postpartum depression for the primary care physician.

Abstract: Postpartum depression (PPD) occurs more commonly in U.S. women than most physicians realize. PPD is present in at least 10% and up to 20% of women in the United States within the first 6 months of delivery. The rate may be 25% or higher in women with a history of postpartum depression after a previous delivery. Over half of all women who develop postpartum depression still suffer symptoms a year later. This condition causes tremendous morbidity in terms of suffering and decreased quality of life. As with other psychiatric disorders, patients with PPD are more likely to seek help from their primary care doctors than from mental health professionals. Therefore, these providers should be equipped with the knowledge and tools necessary to properly care for women with PPD.

Key Words: "baby blues," Edinburgh Postnatal Depression Scale, postpartum depression, postpartum psychosis 

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Postpartum depression (PPD) occurs more commonly in U.S. women than most physicians realize. PPD has been diagnosed in at least 10% and up to 20% of women in the United States within the first 6 months of delivery. (1) The rate may be 25% or higher in women with a history of PPD after a previous delivery. Over half of all women who develop PPD still suffer symptoms a year later. This condition causes tremendous morbidity in terms of suffering and decreased quality of life. As with other psychiatric disorders, patients with PPD are more likely to seek help from their primary care doctors than from mental health professionals. (2)

Diagnostic Criteria

PPD is a clinical term referring to a major depressive episode that is temporally associated with childbirth. Although some women report the acute onset of symptoms shortly after delivery, PPD usually begins within 3 to 6 months after delivery. (3) Symptoms of major depression are listed in Table 1.

The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision uses the term "postpartum" in reference to symptoms of major depressive disorder, bipolar disorder, or brief psychotic disorder beginning within 4 weeks of delivery. (4) Depressive episodes at any time within the first year postpartum, however, also can be considered as being postpartum in onset. (2) The psychiatric postpartum experiences usually are divided into three categories: "maternal blues," PPD, and postpartum psychosis. Although the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision does not apply the "postpartum" modifier to all other psychiatric illnesses, anxiety disorders can also occur initially or worsen during the postpartum period. These anxiety disorders include panic disorder, obsessive-compulsive disorder, and phobias. (4)

Diagnosing PPD can be complicated by the similarity of signs and symptoms of depression and the sequelae of normal childbirth. Subclinical mood fluctuations, which occur frequently during the first 2 weeks after delivery, are considered part of the normal postpartum experience. Therefore, determining the time of symptom onset since delivery may help the physician to distinguish PPD from normal childbirth mood changes. (5)

Many women (50-85%) experience the "maternal blues," also known as the "baby blues," characterized by mild depressive symptoms, anxiety, irritability, mood swings, tearfulness (often for no discernible reason), increased sensitivity, and fatigue. (2), (6), (7) The "blues" typically peak on postpartum Days 4 and 5, may last hours to days, and usually resolve by postnatal Day 10. Although these symptoms may be distressing, they do not reflect psychopathology, and they typically do not affect the mother's ability to function and care for her child. (2)

Finally, PPD should be distinguished from postpartum psychosis, which occurs in 0.2% of childbearing women and usually with onset during the first 4 weeks of delivery. The psychosis is typically manic in nature, (8) and in most cases may be considered a manifestation of bipolar disorder. Bipolar disorder affects 1 to 2% of the population and occurs commonly in women of childbearing years. (9)

Early warning signs for postpartum psychosis include insomnia for several nights, agitation, an expansive or irritable mood, and infant avoidance. When delusions or hallucinations are present, they often involve the infant. Rates of infanticide associated with untreated postpartum psychosis have been estimated to be nearly 4%. (10) Because the woman is at risk for harming herself or her baby (or both), postpartum psychosis is considered a medical emergency. Most patients with postpartum psychosis are treated in an inpatient setting with neuroleptic agents and mood stabilizers.

Certain medical disorders may cause symptoms of depression, and these must be considered in the differential before a diagnosis of PPD is made. Anemia or thyroid dysfunction, for example, are common in postpartum women, and should be assessed with a careful history, physical examination, and possibly laboratory analysis before a patient is diagnosed with PPD. (5) Postpartum thyroiditis is a transient disorder seen in some postpartum patients, manifested by a goiter and hypothyroidism or hyperthyroidism. These findings typically resolve spontaneously. However, some symptoms that these women experience, such as fatigue and hypersomnia, mimic depressive symptoms.

Risk Factors

Although no clear cause of postpartum depression exists, several risk factors for postpartum depression have been identified. Confirmed risk factors include a personal or family history of depression or other psychiatric disease, high levels of psychosocial stress, marital discord, and inadequate social support. (11) Almost one half of all PPD cases are continuations of previous depressive episodes occurring during or before pregnancy. (12) Rapid changes in hormone levels also have been considered a risk factor for PPD; however, no consistent relationship between serum levels of estrogen, progesterone, cortisol, or thyroid hormones and the occurrence of postpartum mood disturbance has been identified. (9)

Women who experience baby blues have an increased risk for PPD later in the postpartum period, especially if the blues symptoms were severe. Of women who met the criteria for PPD 6 weeks after delivery, two thirds were found to have had the baby blues. (13) Similarly, the 10% of postpartum women who experience the "highs," characterized by mild euphoria and increased energy, within the first few days of delivery are more likely to be depressed several months later. (14) Therefore, subclinical mood swings in either direction after delivery are an indication for more intensive follow-up later in the postpartum period.

Other risk factors that have been proposed but not conclusively proven include a history of premenstrual syndrome, young maternal age, any obstetric complications, a low number of past pregnancies, and a failure to successfully initiate breastfeeding. Factors such as education level, infant gender, the type of delivery, and socioeconomic background have not been shown to independently influence the risk of postpartum depression. (11)

Consequences

PPD affects not only the woman it manifests in but also the entire family. Husbands or partners are more likely to develop depression in the postpartum period if their wives develop PPD. (15) The marital relationship is significantly stressed by the occurrence of postpartum depression, leading to deterioration in multiple areas of the marriage. (16)

A majority of studies on PPD and the mother-child relationship have found significant differences between children raised by nondepressed mothers and those whose mothers suffered from PPD. PPD is a traumatic event that can have lasting effects on an infant's development. (5) Infants' and toddlers' cognitive skills, (6) language, (17) attention, (18) and some social skills (12) have been shown to be adversely affected by maternal depression. Children of depressed mothers develop conduct and attention disorders more commonly, (19) and they may suffer from both social and cognitive delays up to age 4 years and beyond. (20)

Some effects of maternal depression on parental attitudes and behaviors include guilt and anxiety about parenting, disappointment about the infant's gender, inflated expectations about the infant's developmental abilities, loss of love for the infant, and thoughts of harming the child. An affected mother may have more negative face-to-face encounters with her infant, inability or lack of attempt to soothe the infant, difficulty enjoying the baby, or she may make hostile expressions toward the infant. The baby may respond with less eye gaze toward its mother, be more drowsy or fussy, and may have less response in interactions with its mother. (12)

Studies of adolescent mothers affected with PPD have shown that these mothers are three times more likely to use alcohol or illicit substances at 4 months postpartum than are nondepressed adolescent mothers. These mothers may also be more likely to abuse their children. (12)

Chaudron (12) suggested that these women likely have difficulty achieving a healthy maternal role and confidence in their parenting skills. Therefore, they may elect not to become pregnant again, to avoid another postpartum depressive episode.

Barriers to Detection

Detecting PPD in postpartum women is complicated by several factors. Women may expect a period of adjustment after delivering a baby, so first-time mothers may not recognize that what they are experiencing is not normal. Second, if a woman does recognize that her mood is not normal, she may be reluctant to admit her feelings, due to fear of being a "bad mother." (5)

Epperson (5) suggested that women who did not receive their prenatal care from a primary care physician or from one with whom they have frequent contact may be confused about where to turn for help. They may not be scheduled to see their obstetrician for several more weeks, and these patients may not identify their baby's pediatrician as an alternate source of assistance.

In addition, with the pressure of managed care to evaluate more patients in a shorter time, psychological issues will frequently only receive cursory attention from even the most thoughtful clinicians. (5) Even when clinicians are aware that reliable PPD screening tools exist, many may be reluctant to use them for fear that the process will be time-consuming and expensive.

Another reason for the lack of screening is that there may be some uncertainty by clinicians about what to do with a woman once she scores at high risk for PPD. (21) There is also a general concern about using medication in breastfeeding women, which makes clinicians less willing to look for the diagnosis of PPD.

To overcome these barriers to the detection and diagnosis of PPD, formal mechanisms for identifying symptoms of depression in postpartum patients should be developed. These include distinguishing PPD from similar disorders, identifying patients who are at risk, instituting formal screening, and providing educational materials to patients about PPD.

Importance of Screening

Many authors have recommended routine screening of postpartum women. (22-25) Despite the availability of screening tools and numerous recommendations for their use, the impression of most authors has been that PPD is not looked for and remains highly underdiagnosed in the United States. (26), (27) Approximately one half of women with clinically significant PPD symptoms remain undetected by medical providers. (12)

Several conditions should be met for a clinical diagnosis or condition to be considered for routine screening in a population. First, the condition should be common enough that routine screening will detect a significant number of cases. Second, there should be evidence that treatment of the condition results in improved outcomes to justify spending resources diagnosing PPD. Third, the screening test also should be inexpensive, safe, and acceptable for the patient and clinician. Depression in general and PPD in particular fit all of the above criteria.

The U.S. Preventive Services Task Force found good evidence for screening for depression in the general population, making this recommendation a Grade B recommendation. This means that the Task Force "recommends that clinicians routinely provide screening for depression to eligible patients." The U.S. Preventive Services Task Force found at least fair evidence that screening for depression improves important health outcomes and concludes that benefits outweigh harms. (28) The same holds true for postpartum depression.

Tools for Screening

There are several tools that have been developed to screen for PPD. The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item, self-rated questionnaire that has been used to screen for PPD throughout Europe, New Zealand, and Australia primary care practices. (8) The EPDS excludes symptoms that may merely suggest physical discomfort, thus confusing depression with the somatic aftermath of childbirth. (2) This form may be filled out by patients as they wait in an examination room. The questionnaire can be quickly scored, and a woman who meets a threshold score can be further assessed.

The EPDS has been studied extensively and has been shown to be highly effective at detecting PPD without a significant number of false-positives or false-negatives. (4), (29) A threshold score of 12 of 30 was shown in one Australian study to detect major depression with a sensitivity of 100% and a specificity of 95.5%. (30) Other PPD screening tools in use include the Postpartum Depression Checklist, (31) the Beck Depression Inventory, and the Center for Epidemiologic Studies Depression Scale. (32)

The 2-, 6-, and 12-month well-baby visits by pediatricians or family physicians are reasonable opportunities to use a brief screening tool. Repeated screens may be used to 1) assess changes in symptom severity to determine the need for referral and intervention, 2) identify women at risk for PPD and women with PPD, 3) identify women who may have suicidal or homicidal ideation, 4) provide mothers a nonverbal means of expressing their emotions, and 5) provide a time for discussion of any other sensitive issues. (12)

Routine use of a screening tool results in a dramatic increase in the rate of identification of PPD. One author found an increase in the rate of diagnosis from 3.7% to 10.7% with the institution of routine administration of the EPDS screening tool. (27)

Providing Patient Educational Materials

As mentioned above, the many barriers to the detection of PPD emphasize the need for improved education to both patients and their families about the signs and symptoms of PPD. There are several support groups that may either supply or suggest various educational materials that are appropriate for office use. These include Depression after Delivery (telephone [phone]PPD) and Postpartum Support International (telephone [phone]). Pamphlets or posters in the office are informational and also serve to remind patients that their providers are concerned about their emotional health. These educational tools help normalize the experience for patients suffering from PPD and help to reduce the possible fear and shame these patients may feel.

Treatment

The treatment of PPD mirrors the treatment of major depression. Psychotherapy, pharmacotherapy, and electroconvulsive therapy have all been shown to be effective treatment plans for PPD. (5) These may be used alone or in combination. Because no modality has been shown to be superior to any other, some authors suggest that the choice of therapy for mild to moderate PPD should be made in conjunction with the patient. (33)

Marital counseling may be necessary when the marital problems are distressing and may be contributing to the woman's depressive symptoms. Interpersonal therapy is another form of psychotherapy that may be suitable for use in postpartum women because it focuses on interpersonal relationships and changing relationship roles. (34)

A woman with PPD with persisting or severe symptoms should be evaluated for antidepressant therapy. Without treatment, these women may have difficulty caring for themselves and their children. Tricyclic antidepressants such as amitriptyline, nortriptyline, imipramine, and desipramine have been prescribed most frequently for both postpartum and major depression. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, fluvoxamine, and paroxetine may be better tolerated by patients and have the advantage of once-daily dosing. (5) SSRIs are more commonly used today because of their equal efficacy and excellent safety profile, and thus are considered first-line therapy for both major depression and PPD. Anxiety symptoms are commonly found in women with PPD; therefore, the addition of an anxiolytic medication, such as a benzodiazepine, may also be helpful in these women. (2)

The use of antidepressants during breastfeeding has been extensively reviewed. (35) The Food and Drug Administration has not approved any psychotropic medication for use during pregnancy or lactation; however, professional guidelines may permit their use in women with PPD who breastfeed. (2) In most cases, infant blood concentrations of tricyclic antidepressants and SSRIs have been below the commercial laboratory detection limit. Studies have shown that antidepressants and their metabolites are passed on to infants through breast milk and that detectable plasma levels of these medications are found in some infants. (36-41) In most cases, these infants tolerated the exposure without difficulty. (36), (37), (42) If infants exposed to antidepressants through breast milk are exhibiting persistent unexplained irritability, plasma concentrations of the drug should be determined to evaluate for drug accumulation. (5) If it is determined that infants are being adversely affected by medications, it may be wise to recommend the discontinuation of breastfeeding in these patients.

The benefit of antidepressant therapy to the mother and child may outweigh the relative risks and must be considered. (2) The risk-benefit analysis must be individualized, considering the maternal illness severity, the maternal support system, the infant's age and health, and the potential effects of either breastfeeding or not on the mother's self-esteem. (12)

Typically, women should remain on the recommended starting antidepressant dosage for approximately 2 weeks before the dosage is increased. If there is no symptom improvement or if the patient's symptoms actually worsen after 2 weeks of treatment, this initial dosage should be increased, with further increases approximately every week. (5) In uncomplicated PPD, clinical improvement is likely within 6 to 8 weeks after the start of the antidepressant treatment. Patients who worsen despite higher medication dosages or who do not respond adequately to a trial on antidepressants should be referred to a psychiatrist for further evaluation. (5)

Prophylactic treatment should be considered in those women at high risk for developing PPD, which includes women with a history of postpartum psychosis, severe recurrent major depressive disorder, or onset of depression during pregnancy. (10) Prophylaxis starts with a prenatal risk assessment and education. Counseling, social support, and increased education are likely to benefit these women and should be offered. Prophylactic antidepressant therapy during the third trimester or immediately after delivery has been found to reduce relapse rates significantly in these women at highest risk for PPD. (2)

Conclusion

Postpartum depression is more common than many clinicians realize, affecting not only the women diagnosed but also the entire family. Approximately 50% of women with postpartum depression may be undiagnosed. Risk factors for PPD should be understood, screening should be performed, and treatment should be initiated when the diagnosis is made. There are several inexpensive, quick, and simple tools to screen for PPD, which can be administered at postpartum pediatric and obstetric visits. Treatment of PPD includes psychotherapy and pharmacotherapy, resulting in improved quality of life and decreased morbidity for this disease.

Key Points

* Postpartum depression (PPD) is more common in the United States than most physicians realize and is a condition that causes tremendous morbidity for patients and their families.

* There are several inexpensive, quick, and simple tools to screen for PPD that can be administered at postpartum pediatric and obstetric visits.

* Treatment of PPD includes psychotherapy and pharmacotherapy, resulting in improved quality of life and decreased morbidity for this disease.

Accepted July 14, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9702-0157

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RELATED ARTICLE: Table 1. Symptoms of major depression

Depressed mood

Anhedonia 

Sleep disturbance (a)

Weight changes (a)

Loss of energy (a)

Decreased concentration, or indecisiveness (a)

Agitation or movement retardation

Feelings of worthlessness or inappropriate guilt

Thoughts of suicide or death

(a) Symptoms also seen after normal childbirth. (5)

CPT Emily C. Clay, MD, and MAJ Dean A. Seehusen, MD

From the Department of Family Practice, Madigan Army Medical Center, Ft. Lewis, WA.

The views contained herein are those of the author and do not reflect official policy of the Army, the Department of Defense, or the United States Government. There has been no financial support or proprietary interest in the preparation of this review article.

Reprint requests to MAJ Dean A. Seehusen, MD, Department of Family Practice, Madigan Army Medical Center, Ft. Lewis, WA 98431. Email: [e-mail]