According to McCoy et al,21 neither patient age nor marital status nor method of delivery appeared to be associated with PPD at four weeks postpartum. Women who were feeding by formula alone were more likely to experience PPD (RR, 2.04) than were those who breastfed their infants. Women who smoked were more likely to be affected by PPD (RR, 1.58) than were nonsmokers.
Additional risk factors for PPD identified by Dennis et al22 included pregnancy-induced hypertension and immigration within the previous five years. Various psychosocial stressors may also represent risk factors for PPD, including lack of social support, financial concerns, miscarriage or fetal demise, limited partner support, physical abuse before or during pregnancy, lack of readiness for hospital discharge, and complications during pregnancy and delivery (eg, low birth weight, premature birth, admission of the infant to the neonatal ICU).11,22,23
It is important to identify women who are at highest risk for PPD as soon as possible. High-risk patients should be screened upon discharge from the hospital and certainly on or before the first postpartum visit.
CLINICAL MANIFESTATIONS
Clinical manifestations of PPD include depressed mood for at least two weeks with changes in somatic functions, such as sleep, energy level, appetite, weight, gastrointestinal functioning, and decrease in libido.3,24 These manifestations are more severe and prolonged than those associated with baby blues (which almost always resolve within two weeks postpartum).2,7
On physical examination, the patient with PPD may appear tearful and disheveled, with psychomotor retardation. She may report that she is unable to sleep even when her infant is sleeping, or that she has a significant lack of energy despite sufficient sleep; she may admit being unable to get out of bed for hours.2 The patient may report a significant decrease in appetite and little enjoyment in eating, which may lead to rapid weight loss.
Other symptoms may include obsessive thoughts about the infant and his or her care, significant anxiety (possibly manifested in panic attacks), uncontrollable crying, guilt, feelings of being overwhelmed or unable to care for the infant, mood swings, and severe irritability or even anger.2
Severe fatigue may warrant hemoglobin/hematocrit evaluation and possibly measurement of serum thyroid-stimulating hormone (TSH).25,26
It is essential to rule out postpartum psychosis, which is associated with prolonged lack of sleep, confusion, lapsed insight, cognitive impairment, “grossly disorganized behavior,”10 and delusions or hallucinations.5,10 The patient should be asked specifically about unusual or bizarre thoughts or beliefs concerning the infant, in addition to thoughts of harming herself or others, particularly the infant.10
SCREENING
Numerous researchers have suggested that PPD is underrecognized and undertreated.5,6,18,27,28 Screening for PPD in the United States is not standardized and is highly variable.29 The American Academy of Family Physicians supports universal screening for PPD at the first postpartum visit, between two and six weeks.30,31 According to a 2010 Committee Opinion from the American College of Obstetricians and Gynecologists, “at this time, there is insufficient evidence to support a firm recommendation for universal antepartum or postpartum screening; however, screening for depression has the potential to benefit a woman and her family and should be strongly considered.”32
As the AHRQ14 notes, symptoms of PPD may not peak in some women until after their first postpartum visit, and providers of family medicine, internal medicine, and pediatric care may also be in a position to provide screening. The initial well-baby examination by the pediatric primary care provider, for example, presents an important opportunity to screen new mothers for PPD. According to Chaudron et al,33 the well-being of the infant should outweigh any scope-of-practice concerns, practitioner time limitations, or reimbursement issues; rather, screening efforts can be considered “tools to enhance [mothers’] ability to care for their children in a way that is supportive and not punitive.”33
In 2009, Sheeder and colleagues28 reported on a prospective study of 199 mothers in an adolescent maternity clinic who were screened using the Edinburgh Postnatal Depression Scale (EPDS)34 at each well-baby visit during the first six months postpartum. The authors concluded that the optimal time for screening for PPD in this setting is two months after delivery, although repeated screening may identify worsening of depressive symptoms.28
Several screening tools are available for the detection of PPD, particularly the EPDS,34 the Postpartum Depression Screening Scale,35 and the Patient Health Questionnaire–936-38 (see table,11,13,34-37 ). The EPDS, a widely used and well-validated formal screening tool,27,37 is a 10-item self-report questionnaire designed to detect depression in the postpartum period. Cox et al,34 who developed the scale, initially reported its sensitivity at 86% and specificity at 78%21; since then, the tool’s reported sensitivity for detecting major depression in the postpartum period has ranged from 60% to 96%, and specificity from 45% to 97%.6,39 The EPDS has been shown to result in a diagnosis of PPD in significantly more women than routine clinical evaluation (35.4% vs 6.3%, respectively).40 It is possible to administer the EPDS by telephone.41
