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CME

EARN CATEGORY I CME CREDIT by reading this article and the article beginning on page 26 and successfully completing the posttest on page 55. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of February 2013.

LEARNING OBJECTIVES
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Differentiate postpartum depression (PPD) from the “baby blues” and postpartum psychosis. Apply standardized instruments for objective screening for PPD as a routine part of care. Discuss appropriate alternatives for the management of patients with PPD. Identify common complications of unrecognized and improper treatment of patients with PPD.

Postpartum depression: Symptoms, diagnosis, and treatment approaches
Maternal depression folowing the birth of a baby can impact the quality of life of both mother and child over the course of their lifetimes and may have life-threatening effects.
Genevieve A. DelRosario, MHS, PA-C; A. Caroline Chang, MMS, PA-C; Elizabeth D. Lee, BA

T

he birth of a baby is usually an eagerly awaited and joyful event and a milestone in the life of a family. Many women are surprised, then, when this joyful event is followed by sadness, mood swings, and anhedonia. This response should not, however, be a surprise to medical providers. Postpartum depression (PPD) is the most common complication of childbearing, occurring in approximately 15% of women during the postpartum period, with some sources suggesting that the true incidence may be higher.1-4 The potential impacts on the mental and physical health of the mother and her infant may be profound and lifelong, as bonding, preventive care, and health maintenance are often suboptimal during the first few critical months of life. Beyond the clinical implications for both the mother and her infant, direct and indirect financial implications of this condition are substantial as well.5 Given the frequency and severity of PPD, all medical providers should recognize the signs of PPD and know the basics of therapy. In particular, PAs working in obstetrics and gynecology, pediatrics, and family and emergency medicine should be knowledgeable regarding this common complication. This article will review the pathophysiology, risk factors, signs and symptoms, diagnosis, treatment, and sequelae of postpartum depression. The definition of perinatal depression differs from other forms of depression only in terms of timing. The Diagnostic and Statistics Manual, Fourth Edition, Text Revision
50 JAAPA • FEBRUARY 2013 • 26(2) • www.jaapa.com
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DEFINITIONS

Another factor that may contribute to postpartum depression is the decrease of maternal brain DHA and other omega-3 PUFAs during pregnancy. for example.8 hormonal shifts may contribute to an episode of PPD in predisposed individuals. or bizarre delusions. poor marital and social support.jaapa. and disorganized behavior. with some sources suggesting the true incidence may be higher. Thus.3. This is a psychiatric emergency in which the safety of the new mother and her child or children may be jeopardized. Additionally.8 Given estrogen’s effect on MAO-A levels. however.6 Clinically. for example. as well as decreased levels of the omega-3 polyunsaturated fatty acid (PUFA) docosahexaenoic acid (DHA). and psychological modalities. However.8. but research has been inconclusive. especially those practicing in primary care fields and emergency medicine. grandiose. Because depressive symptoms are typical of hypothyroidism. mood swings. serotonin. ■ Patients with postpartum psychosis may develop paranoid.13-15 The most significant factors appear to be a history of a depressive episode or MDD and occurrence of stressful life events. confused thinking. a mother may hear voices telling her she should kill her infant. little is known about its specific etiology. and GABA have well-documented relationships with psychiatric diseases.9. promising epigenetic studies suggest that genetic predisposition may play a significant Women diagnosed with PPD often demonstrate one or more of the following risk factors: history of a depressive episode or MDD. including hospitalization. postpartum thyroiditis must be included in the differential diagnosis of a woman presenting with PPD.3. bright light therapy. occurring in as many as 15% of women during the post- partum period. including the stress associated with child care. including cognitive behavior and interpersonal therapy.4. Low socioeconomic status has also been postulated to be a risk factor for PPD.17 SCREENING AND DIAGNOSIS Postpartum screening is recommended by numerous sources. grandiose. Postpartum psychosis has a rapid onset. approximately 6% to 9% of women develop postpartum thyroiditis.2.11 Elevated levels of estrogen and progesterone that are present in the third trimester of pregnancy are known to drop exponentially early in the postpartum period. there is further potential for a secondary effect on dopamine and norepinephrine levels. The disorder is a psychiatric emergency in which the safety of the new mother and her child or children may be jeopardized. Suggested mechanisms include changes in estrogen.9 Alternations in the hypothalamicpituitary axis and thyroid dysfunction have also been considered. All clinicians. postpartum psychosis is a manifestation of bipolar disorder. as well as prescription of omega-3 polyunsaturated fatty acids. Other approaches include exercise. brain fattyacid content has not been studied extensively in humans.10 Furthermore. multiple gestation. mood swings. an exact mechanism remains unclear.1. Immediate treatment.9 Estrogen appears to affect serotonin levels and serotonin receptors both directly and secondarily through MAO-A levels. all of which vary from their normal state. or bizarre delusions.5.2 Regardless of the etiology. connection between postpartum thyroiditis and PPD has been hypothesized. must be considered for this population.12 In addition.2 Most women will experience mood swings. which may present with symptoms of either hyperthyroidism or hypothyroidism. and stressful life events. gestational diabetes.4.16.10 RISK FACTORS Despite increasing awareness of PPD. Although decreased activation of the hypothalamicpituitary axis after childbirth has been hypothesized as a contributing factor in the development of PPD. must be able to differentiate the more serious postpartum psychosis from these other conditions (Table 1). progesterone. confused thinking.9. In many cases. in the weeks following the birth of a child. This condition is usually mild and transitory.2 The practicing PA should be diligent in differentiating between this common occurrence and a true major depressive episode. including antidepressants and hormone administration. patients and their partners should be educated regarding warning signs of a true depressive disorder and encouraged to contact their medical provider if significant concerns arise. ■ Among the treatment options are pharmacotherapy. resolving in the first 10 days of an infant’s life.com • FEBRUARY 2013 • 26(2) • JAAPA 51 . citing an onset of depressive symptoms within 4 weeks of giving birth. all medical providers should know the signs of postpartum depression and the basics of therapy. and acupuncture and massage.3 Because serotonin.5 while progesterone appears to affect GABA-A receptors. including the American Academy of Pediatrics (AAP)18 and KEY POINTS ■ Postpartum depression is the most common complication of childbearing. monoamine oxidase A (MAO-A) and gamma-aminobutyric acid (GABA) levels.9. Patients may develop paranoid. www.7 PATHOPHYSIOLOGY OF PPD role in a woman’s response to environmental factors regarding PPD development. and disorganized behavior. PPD is often diagnosed when symptoms occur within 12 months of a child’s birth.3.(DSM-IV-TR) defines postpartum depression by adding a specifier to the discussion of major depressive disorder (MDD). MAO-A.3. generally occurring within the first 4 weeks after childbirth but in some cases as early as 2 days postpartum. and is not accompanied by suicidal ideation.1. a mother may hear voices telling her she should kill her infant. commonly called the baby blues .

particularly while nursing.23 These instruments are useful for screening.23 Baby blues Onset Duration Incidence Suicidal ideation 2-3 days postpartum <10 days 80% No Postpartum depression Often 4 weeks. Major depressive disorder. problem-focused modality. in which patients are encouraged to change thought patterns and improve coping behaviors. and one of the five must be either depressed mood or anhedonia to make a diagnosis of MDD. on themselves and the infant. such as nortriptyline and imipramine. In addition. postpartum depression. psychological therapy. many of the symptoms (sleep deprivation.CME Postpartum depression the Academy of Breastfeeding Medicine. a positive screen should prompt the clinician to conduct a complete interview to determine if the patient meets criteria for a major depressive episode. Psychotherapy may also be used effectively in combination with pharmacotherapy. Rather.2 This easily readable questionnaire assesses a patient’s mood over the past week.24 Among the pharmacologic options.2 One notable limitation in the definition of PPD is that the postpartum onset specifier in the DSM-IV-TR does not account for whether or not depressive symptoms were present during time periods prior to pregnancy.2 Commonly used psychological modalities include cognitive behavior therapy.6 Recent expert opinions suggest that onset within the first 3 months is a more clinically accurate criterion. or both are often considered first-line therapy. and that symptom onset of PPD may occur at any point within the first 12 months after childbirth. and patient desires. treatment.24 Pharmacologic options While women may be hesitant to use medicines. often an acute episode of an underlying bipolar disorder 1-2/1. Nondirective counseling and enhancement of peer and partner support are strategies also supported by the literature. Comparison of baby blues. a designation of symptom onset within 4 weeks following birth allows for a diagnosis of PPD. a time-limited. change in weight or appetite.24 The choice to use antidepressants may be based in part on the severity of the depression. sleep disturbance. Psychological or psychosocial options Psychotherapy is an effective treatment for PPD. but they should not be used alone to make the diagnosis of PPD.7. many current medications are effective in the treatment of PPD. can be completed and scored in just a few moments. paroxetine.21 Multiple tools exist to screen for PPD.2 Thus.25 A third class of treatment is hormonal therapy.jaapa. the use of medications.2 The questionnaire can be accessed online and is most commonly administered at the 6-week postpartum visit of the mother or at the 2-month well-child checkup. such as the risk of overdose. transdermal estradiol has been Table 1. Translations are available in more than 35 languages.22 Other validated screening tools include the Center for Epidemiologic Studies of Depression instrument (CES-D). and education for postpartum depression.6 As previously noted.20 The American College of Obstetrics and Gynecology recommends that both antenatal and postnatal screening for depression be “strongly considered.” although the organization stops short of recommending universal screening at this time. Because the postpartum drop in estrogen levels may contribute to the onset of depression. which asks respondents to choose from a closed set of possible responses.19 Legislation has been passed at the national level and by several states to improve screening. psychomotor disturbance. a detailed history is crucial to carefully differentiate between PPD and a normal postpartum course. and sertraline have each been effective in clinical trials. and the Postpartum Depression Screening Scale (PDSS). A total score of greater than 12 or any positive response to the item “the thought of harming myself has occurred to me” should prompt a more complete assessment for depression. the Patient Health Questionnaire (PHQ-9). and interpersonal therapy. Each response is given a score of 0 to 3. which is both sensitive and specific in detecting postpartum depression. or thought of death or suicide. fatigue) may be experienced as part of routine infant care or secondarily from sleep deprivation related to infant care and do not constitute a depressive episode on their own. However. the selective serotonin reuptake inhibitors (SSRIs) are considered to be the first-line choice for postpartum depression. fatigue. inappropriate guilt. are well-studied and have proven effective in many cases. TREATMENT Pharmacologic options. and other therapeutic approaches are available for the treatment of PPD.25 Tricyclic antidepressants (TCAs). anhedonia. eg. Fluoxetine. weight changes. they remain second-line medications because of safety concerns. with other options used as adjuvant therapy. particularly in women with mild to moderate symptoms.6 Five of these symptoms must be present within a 2-week period.com . antidepressants. as outlined in the DSM-IV-TR.000 May be present 52 JAAPA • FEBRUARY 2013 • 26(2) • www. may be up to 1 year >2 weeks 10%-15% May be present Postpartum psychosis Within 2-4 weeks after delivery Variable. Counseling. This approach may be a particularly attractive option to women who are breastfeeding and wish to avoid pharmacotherapy because of the effects of certain medications. is characterized by a possible symptom combination of depressed mood. and postpartum psychosis2. The 10-question form. diminished concentration. The most commonly used instrument is the Edinburgh Postnatal Depression Scale (EPDS). availability and affordability of psychotherapy.

PAs can help new parents through this transition to ensure the healthiest family possible. prescribe the starting dose for 4 days. as these agents are associated with fewer adverse effects for both the mother and child.edu/pediatrics/ downloads/edinburghscale.33 Women with PPD are less likely to breastfeed and to ensure routine safety measures for their infants. the possible effects on infants and on a mother’s ability to produce milk. and Elizabeth Lee is a student. bright light therapy.12. Thus. The most concerning factor of PPD is the significant impact of this disorder on both the mother and her child. mothers with PPD have been shown to access preventive care. increase the amount of medication to the lowest dosage in the usual treatment range. with some limited success. and other drugs that may be used instead.com • FEBRUARY 2013 • 26(2) • JAAPA 53 .12 Additionally. but long-term data are limited.pdf LactMed http://toxnet.34 Poor health.24 Finally.12. and women are strongly encouraged to breastfeed exclusively for the first 6 months of their child’s life by both the AAP and the World Health Organization. However.2 Safety of medications in lactation may be checked online at LactMed. The database provides such information as the level of each medication secreted in breast milk. If that dose is well-tolerated.ucsf.gov/cgi-bin/sis/ htmlgen?LACT symptoms of PPD may caus e feelings of guilt in a new mother who is not enjoying this period. and aggressive screening for suicidal ideations should be performed.12. are often reported by mothers with PPD. The benefits of breastfeeding for both the mother and infant are well-understood.12 as well as serving as an additional cause for the previously discussed psychiatric disorders observed in children of depressed mothers.28 However. PPD may decrease the quality of the relationship between the mother and her partner.9.nih. the www. maternal PPD can increase the risk of low self-esteem.34 Postpartum depressive mothers have also shown more aggressive behavior toward the infant or fear of being alone with the baby.jaapa. as the excretion of these agents in breast milk is very low. study results have been mixed in terms of the efficacy of PUFAs in reducing symptoms of postpartum depression.32 Mothers with PPD are more likely to utilize health care resources for somatic complaints than mothers without PPD. unless there is evidence that the medication is unsafe in lactation.30.24 While efficacy data are limited. or conduct disorder during childhood to adolescence. or even play. depression or anxiety disorders. JAAPA The authors are affiliated with the Department of Physician Assistant Education.fresno. SEQUELAE OF PPD SEE THE ONLINE VERSION OF THIS ARTICLE TO LINK TO The Edinburgh Postnatal Depression Scale http://www. Sertraline and paroxetine may be considered in women who are naive to antidepressant use. developmental activities. Mothers with PPD may spend less time engaged in bonding activities.30. paroxetine has been linked to an increased risk of cardiac defects in the developing fetus and should thus be used with caution in a woman who may become pregnant again while undergoing therapy. such as eicosapentaenoic acid (EPA) and DHA. omega-3 PUFAs.2. women should be treated for an additional 6 to 9 months before tapering the medication in order to avoid relapse.12 In their role as caregiver. In addition. Combined with the widespread cultural assumption that motherhood should be a time of elation in a woman’s life. St. and treatment.28 Continuing use of a medication to which the patient has already responded well is reasonable.26.34 In cases of severe PPD. Louis University.2. along with sleep and behavior problems of the infant.31 Further research is needed to determine whether PUFAs can be an effective alternative to antidepressant use in the postpartum period. St.32 Regardless.33. a peer-reviewed and referenced database of drugs to which breastfeeding mothers may be exposed.29 Additional therapeutic options Other modalities exist that may be beneficial to women with PPD. Genevieve DelRosario is an assistant professor and clinical director of the PA program.34 Such behaviors can negatively impact the development of the child’s communication and language skills. CONCLUSION Postpartum depression can make the first months of an infant’s life challenging for both the mother and her newborn child. With careful screening. After the depression has resolved. Louis.9. at a decreased rate while utilizing emergency services for their infants at a higher rate than mothers without PPD. Concomitant lifestyle modifications should be encouraged. including well-baby visits and routine vaccinations. Electroconvulsive therapy may also be considered for depression that is refractory to other treatments.25 Regardless of which medication is chosen.nlm. No relationships to disclose. and tactile stimulation and soothing of their infants may be decreased. These include exercise.2 Antidepressants and breastfeeding The use of antidepressants is a difficult choice for many patients and practitioners when a woman is breastfeeding. have been considered as possible alternative therapy. aggressive behavior directed toward the infant may result in abuse or infanticide. Missouri. However. more data are needed before a clinical recommendation can be made. Mothers with PPD may feel a sense of detachment from their infants.2 Such feelings often serve to worsen PPD symptoms. and acupuncture and massage.33 Whether or not maternal suicide occurs more often in women with MDD during the postpartum period than in women with MDD who are not postpartum remains controversial.9. Caroline Chang is an instructor. suicide remains a significant concern. all these options are relatively safe and may have other health benefits.tried. however. diagnosis. PPD can have long-lasting effects on the child. the use of antidepressants in breastfeeding women is a decision to be carefully considered and made by the patient in conjunction with her medical provider.27 There is little evidence suggesting that breastfeeding while using certain antidepressants is unsafe.

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