Clinical Review

Probing Postpartum Depression

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Prevalence of postpartum depression among women who have given birth in the previous year could be as high as 20%. Which women are at risk, and where does each affected patient belong on the spectrum from baby blues to postpartum psychosis? It is essential for every clinician who provides care for childbearing women to be familiar with current screening and treatment options—and the controversies involved.



 

Care of the postpartum patient is an important component of primary care practice—particularly for clinicians who provide women’s health care and are called upon to effectively screen, identify, and manage patients who may be at risk for postpartum depression (PPD). Effective management of the postpartum patient also extends to care of her infant(s) and ideally should involve a multidisciplinary team, including the primary care provider, the pediatrician, and a psychologist or a psychiatrist.1

PPD is commonly described as depression that begins within the first month after delivery.2 It is diagnosed using the same criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)3 as are used to identify major depressive disorder. According to the DSM-IV, PPD begins within the first four weeks after the infant’s birth.2,3 Although onset can occur at any time between 24 hours after a woman gives birth to several months later, PPD most commonly occurs within the first six weeks after delivery.1

The woman with PPD may be reluctant to report her symptoms for a number of reasons, including lack of motivation or energy, fatigue, embarrassment that she is experiencing such symptoms during a presumably happy time in her life—even fear that her child may be removed from her care.4 In addition to depressive symptoms (eg, sleeping difficulty, appetite changes, anhedonia, and guilt), women affected by PPD often experience anxiety and may become obsessed with the health, feeding, and sleeping behaviors of their infants.1,5

Postpartum mood disorders occur in a spectrum, ranging from postpartum baby blues to postpartum psychosis. By DSM-IV definition, a diagnosis of major or minor PPD requires that depressed mood, loss of interest or pleasure, or other characteristic symptoms be present most of the day, nearly every day, for at least two weeks.3,6 PPD must be differentiated from the more common and less severe baby blues, which usually start two to three days after delivery and last less than two weeks.2,7 Between 40% and 80% of women who have given birth experience baby blues, which are characterized by transient mood swings, irritability, crying spells, difficulty sleeping, and difficulty concentrating.8 Experiencing baby blues may place women at increased risk for PPD.9

Postpartum, or puerperal, psychosis occurs in approximately 0.2% of women,10 with an early and sudden onset—that is, within the first week to four weeks postpartum. This severe condition is characterized by hallucinations and delusions often centered on the infant, in addition to insomnia, agitation, and extreme behavioral changes. Postpartum psychosis, which can recur in subsequent pregnancies, may be a manifestation of a preexisting affective disorder, such as bipolar disorder.10 Postpartum psychosis is considered an emergent condition because the safety and well-being of both mother and infant may be at serious risk.2,10

EPIDEMIOLOGY AND RISK FACTORS

PPD is often cited as affecting 10% to 15% of women within the first year after childbirth.11,12 Currently, reported prevalence rates of PPD range from 5% to 20% of women who have recently given birth, depending on the source of information. Among 17 US states participating in the Pregnancy Risk Assessment Monitoring System, a CDC surveillance project, prevalence of self-reported PPD symptoms ranged from 11.7% in Maine to 20.4% in New Mexico.11,13 According to the Agency for Healthcare Research and Quality (AHRQ),14 the prevalence of major or minor depression ranges from 6.5% to 12.9% at different times during the year following delivery, although study design varied throughout the research used, and confidence intervals were deemed wide.14,15

Nevertheless, according to results from a systematic review of 28 studies, the prevalence of minor or major depression is estimated at up to 19.2% of women during the first three months postpartum, and major depression in up to 7% during that time.16 A 2007 chart review of 4,398 US women experiencing live births identified PPD in 10.4%.17

Incidence of PPD is “much higher than the quoted rate of 10% to 15%,” concludes Almond18 after a comprehensive literature review. The condition also affects women globally, the British researcher reports: Not only did she find numerous data on the incidence of PPD in high-income countries, including the US, the United Kingdom, and Australia, but she concluded that incidence rates of PPD in developing countries are grossly underestimated, according to epidemiologic studies in low- and middle-income countries (eg, Pakistan, Indonesia, Vietnam). Additionally, the risk factors for PPD are likely to be influenced by cultural differences, and attempts to identify PPD must be culturally sensitive.18

Several risk factors have been associated with PPD. Perhaps the most significant risk factor is a personal history of depression (prior to pregnancy or postpartum); at least one-half of women with PPD experience onset of depressive symptoms before or during their pregnancies,19,20 and one research group reported a relative risk (RR) of 1.87 for PPD in women with a history of depression, compared with those without such a history.21 Thus, women previously affected by depression should be carefully monitored in the immediate postpartum period for any signs of depressed mood, anxiety, sleep difficulties, loss of appetite or energy, and psychomotor changes.

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