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Postpartum depression often tricky to diagnose.

LAS VEGAS -- Diagnosing postpartum depression can be tricky because of the wide range of body changes that occur during the postpartum period, but vigilance is warranted with mothers who express a lack of sleep and a lack of social support.

One of the best questions to ask is: "Are you able to sleep when the baby sleeps?" Susan Hatters Friedman, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. "This gives you information about depression and insomnia. Make sure to ask about anxiety symptoms. Also ask about any thoughts of suicide or harming the infant, and support from family and friends when she's under stress and taking care of the baby."

According to Dr. Friedman, a perinatal and forensic psychiatrist at Case Western Reserve University, Cleveland, social risk factors for postpartum depression (PPD) include being a victim of intimate partner violence and/or abuse, negative life events, decreased social support, relationship issues, and socioeconomic status. Psychological risk factors include anxiety / depression in pregnancy, personal or family history of PPD, and substance misuse. Biological risk factors include medical illness, multiple births, and having an infant with low birth weight/prematurity.

PPD affects 10%-20% of new mothers and peaks at 12 weeks. Postpartum psychosis, meanwhile, occurs in about 1-2 of every 1,000 deliveries. Anxiety comorbidity is common.

In the neonatal intensive care unit (NICU), PPD rates might increase from 28% to 70% depending on the study. Risk factors include personal or family history, disturbed relationships, unfavorable socioeconomic factors, and stressful life events. Obstetrical risk factors might include conception by assisted reproductive technologies and having a stillbirth in the year before conception. NICU-specific risk factors include less-effective coping strategies, greater perception of maternal role disruption, and decreased perception of nursing support. "A lot of mothers [in the NICU] talk to me about being on a roller roaster every day about what's going to happen with their baby," Dr. Friedman said.

The most widely used measure to screen for PPD is the 10-item self-rating Edinburgh Postnatal Depression Scale. A total score of 10 or more is considered a flag for the need to follow up for possible depressive symptoms. She advises clinicians to pay particular attention to how patients respond to item No. 10 on the scale, which reads, "The thought of harming myself has occurred to me." (Optional answers range from "Yes, quite often" to "Never.") She also recommends administering the screen at both pediatric and obstetrical office visits, "because mothers are more likely to attend a pediatrics appointment than her own [postpartum] follow-up."

The differential diagnosis of PPD includes the baby blues, postpartum psychosis, postpartum anxiety/ PTSD, medical causes, substance use disorder, and PPD in bipolar disorder. Baby blues is not synonymous with PPD. It affects the majority (50%80%) of new mothers and is characterized by emotional sensitivity, mood lability, and irritability. It usually occurs within 5 days and resolves by the second week post partum.

Postpartum psychosis (PPP) occurs in about 1-2 of every 1,000 deliveries, typically in the first 2 weeks after delivery. The onset occurs rapidly, and PPP is most frequently correlated with bipolar disorder over time. PPP itself is characterized by grandiose bizarre delusions, mood lability, hallucinations, confusion, and disorganized behavior. "This can occur as a new onset of mental illness as well, so getting collateral information about her behaviors is important," she said.

Dr. Friedman explained that those events occur post partum largely because of sleep deprivation and increasing stress as the woman adjusts to a mothering role. Hormonal shifts also occur, with a drop in estrogen levels. Obstetrical complications also might factor in.

Postpartum obsessive-compulsive disorder (OCD) is commonly comorbid with PPD and is distinguished by ego-dystonic intrusive thoughts. The mother might have intense distress that she is going to harm the infant and might start to avoid holding the baby out of concern.

"Common things I've heard from women with postpartum OCD are: 'I'm afraid I'm going to put the baby in the microwave or in the oven instead of dinner' or 'I'm afraid I'm going to leave the baby in the car overnight and she'll freeze to death,'" she said.

Postpartum PTSD can be triggered by a traumatic event experience in the birthing process, such as an emergency C-section. Affected mothers avoid the infant and hospital, "reexperience" the trauma, and are easily starded, irritable, and disconnected. Dr. Friedman also noted that early parental PTSD symptoms predict sleep and eating problems in childhood and less sensitive/more controlling maternal behaviors.

Medical conditions that mimic PPD include anemia, thyroid disease, hypoactive delirium, infections, and alcohol/substance use disorder.

The best available data show that mothers with PPD are more withdrawn, are more disengaged, display more hostility, and are more likely to have disrupted attachment with their babies, Dr. Friedman said. They also are less likely to employ healthy child development practices and to breastfeed. Untreated depression might lead to psychotic symptoms, suicide, or homicide. Paternal PPD also occurs in an estimated 10% of fathers and is moderately correlated with maternal PPD.

Potential risks of PPD include impaired bonding, attachment disturbance, language development, cognitive skills, and behavior problems.

Potential risks of untreated PPD include child neglect or abuse because of active symptoms, suicide, and psychotic or maltreatment-related infanticide. "If the mother is taking about harming herself, I often ask: 'Have you thought of what would happen to your baby if you were to take your own life?'" Dr. Friedman offered. Peripartum suicide risk is lower than in the general female population, but it represents about 20% of peripartum deaths. Overdose is the most common method. "However, uncommon and dramatic methods are more common in this population," she said. "Teens and stigmatized single mothers are at greater risk."

Dr. Friedman noted that clinicians face risk of a malpractice lawsuit if they fail to treat, abandon the patient, and fail to provide informed consent, and if there are bad outcomes. The best approach is to proactively communicate with the patient, partner, pediatrics, and obstetrics. "Conduct an individual risk-benefit assessment with the individual patient's history," she advised. "Don't do anything knee-jerk. Consult when needed, document, and consider lactation and future pregnancy possibility in women of reproductive age."

Nonpharmacologic therapy might be the first line of treatment for mild to moderate symptoms.

Dr. Friedman reported having no disclosures.



Caption: Potential risks of untreated PPD include child neglect or abuse and suicide, said Dr. Susan Hatters Friedman.

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Author:Brunk, Doug
Publication:Clinical Psychiatry News
Date:Mar 1, 2019
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