Postpartum Depression: Beyond The Blues

POSTPARTUM DEPRESSION
BEYOND THE BLUES

INCIDENCE OF DEPRESSION
Each year, 15% to 20% of adults in the

United States experience a major depression
The incidence among women is twice that

of men and peaks between 18 to 44 years of
age - the childbearing years
DEPRESSION IN WOMEN
Women are at increased risk of mood
disorders during periods of hormonal
fluctuation-
premenstrual
postpartum
perimenopausal
THE RANGE OF POST-
DELIVERY MOOD
DISORDERS
50% to 80% of women experience transient
“baby blues” within the first two weeks
following delivery
0.1% to 0.2% of women experience
postpartum psychosis usually within the
first 4 weeks following delivery
6.8% to 16.5% of women experience
postpartum depression (PPD) also known as
postpartum major depression (PMD)
Onset can be as early as 24 hours or as late

as several months following delivery
SYMPTOMS OF
Hopelessness Loss of pleasure in activities
Helplessness Mood changes
Persistent sadness Inability to adjust to role of
motherhood
Irritability Inability to concentrate
Low self-esteem Sleep /appetite disturbances
RANGE OF SYMPTOMS
Symptoms range-
from mild dysphoria
to suicidal ideation
to psychotic depression
DURATION OF SYMPTOMS
Untreated, symptoms can last:
several months
into the second year postpartum

THE ETIOLOGY OF
Various theories based in physiological
changes have been postulated:
hormonal excesses or deficiencies of estrogen,
progesterone, prolactin, thyroxine, tryptophan,
among others
ETIOLOGY OF POSTPARTUM
DEPRESSION
Other theories cite numerous psychosocial
factors associated with PMD:
marital conflict
child-care difficulties (feeding, sleeping, health
problems)
perception by mother of an infant with a
difficult temperament
history of family or personal depression
Higher rates of depression were
noted among women who:
Had less than a high school Reported being abused before
education or during pregnancy
Were less than 19 years old Had 0 to 1 person as a source
of social support
Resided in a household with Were not married
an income <$15,000
Experienced an unintended Reported 6 to 18 stresses
pregnancy during pregnancy (sick family
member, divorce, etc.)
THE IMPACT OF
LONG TERM
CONSEQUENCES OF PMD
Negative impact on the infant ‘s social,

emotional and cognitive development
2 month old infants of mothers with PMD had

decreased cognitive ability and expressed more
negative emotions during testing
LONG TERM
CONSEQUENCES OF PMD
Babies of mothers
with PMD were
perceived by their
mothers as more
difficult to care for
and more bothersome.
& MATERNAL MORTALITY
In recent years, there have been two

maternal deaths due to suicide by women
within one year of giving birth.
Neither woman had been screened for
postpartum depression
RISK FACTORS FOR PMD
-Family history of mood -Child-care difficulties:
disorder feeding, sleeping, health
-Client history of mood -Marital conflict
disorder prior to pregnancy
-Anxiety/depression during -Stressful life events
pregnancy
-Previous postpartum -Poor social support
depression
-Baby blues following current
delivery
INTERVENTIONS
SCREENING FOR PMD
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
Be unable to recognize she is depressed

A WOMAN MAY:
Believe her symptoms are “normal” for new

moms
A WOMAN MAY:
Fear being labeled a “bad mother” if she

admits her maternal experience does not
meet society’s picture of bliss
A WOMAN MAY:
Feel she is going crazy and fears her baby

will be taken from her
WHEN TO SCREEN FOR PMD
At preconception visit
During prenatal intake & subsequent visits
During postpartum exams
During infant’s WCC & WIC visits
When infant is seen for sick care or in ER
At early intervention home visits
At family planning visits during the first
year postpartum
At mother’s visits for routine episodic care
SCREENING TOOLS
There are several tools available:
Edinburgh Postnatal Depression Scale (EPDS)
The Mills Depression & Anxiety Checklist
The Center for Epidemiological Studies
Depression Scale (CES-D)
Others, often on various websites for mental
health
A WORD ABOUT
SCREENING TOOLS!
Be familiar with the tool - its validity and
limitations
Have a referral network available for
women screening positive
Document the screening and any referrals
made
Follow-up with your client to assure that
she received needed assistance
EDINBURGH POSTNATAL
DEPRESSION SCALE (EPDS)
Designed for home or outpatient use

Consists of 10 questions
Can be completed in approx. 5 minutes
Reviews feelings the previous 7 days
Scored 0-3 depending on symptom severity
Depending on study, cut off is 13 - 9 points
TREATMENT
1. Educate the woman and her support

system regarding the diagnosis of
postpartum depression.
TREATMENT OPTIONS
Pharmacological intervention
Counseling, individual and/or group
Support groups
PHARMACOLOGICAL
INTERVENTION
Use of tricyclic antidepressants and
selective serotonin reuptake inhibitors
(SSRIs) may be indicated for both non-
nursing and nursing mothers
Have low incidence of infant toxicity and
adverse effects during breastfeeding*
Decisions regarding use while breastfeeding
must be on a case by case basis
OTHER CONSIDERATIONS:
Provider must be familiar with agents and
the hepatic function of mother and infant
Client must be informed of risks/benefits of
treatment Vs. no treatment for herself and
her infant
unknown impact of long-term use of
medications on neurodevelopment of infant
Other Considerations - Cont.
If the woman chooses to breastfeed while
on psychotropics, she should work
collaboratively with a psychiatrist and her
pediatrician
If the infant experiences insomnia or other
behavior changes, his serum should be
assayed for the presence of medication
Document all discussions regarding
treatment in the client’s chart
COUNSELING
Know referral sources in your locale,
especially those that:
accept Medicaid
utilize a sliding fee
will develop a payment plan with the client
offer free counseling
Be familiar with indigent drug programs
available through various pharmaceutical
manufacturers
Counseling - Cont.
Any woman with symptoms of psychosis or
with serious suicidal/homicidal ideation
should be referred for emergency
psychiatric evaluation
SUPPORT GROUPS
Numerous postpartum support groups are

available. Contact:
Local mental health agencies
Hospitals
Websites

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POSTPARTUM DEPRESSION

BEYOND THE BLUES

Each year, 15% to 20% of adults in the

The incidence among women is twice that

Onset can be as early as 24 hours or as late

into the second year postpartum

Negative impact on the infant ‘s social,

2 month old infants of mothers with PMD had

In recent years, there have been two

Be unable to recognize she is depressed

Believe her symptoms are “normal” for new

Fear being labeled a “bad mother” if she

Feel she is going crazy and fears her baby

Designed for home or outpatient use

1. Educate the woman and her support

Counseling, individual and/or group

Numerous postpartum support groups are

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