PRINTABLE PAGE

Postpartum Depression

By Jeanine K. Morris-Rush, MD, and Peter S. Bernstein, MD, MPH
Originally published in Medscape Women's Health 7(1), 2002

Introduction

In the wake of the Andrea Yates case, there has been increased awareness about postpartum psychiatric disorders. Affective disorders, particularly depression, occur frequently during the postpartum period. Postpartum mood disorders include the "baby blues," postpartum depression, and postpartum psychosis. The postpartum blues, or "baby blues," are very common, affecting 70% to 85% of new mothers.1 Usually, postpartum blues begin 3 days after delivery and resolve within 14 days if left untreated. Postpartum depression is more severe. By definition, the depression must be present for more than 2 weeks in order to be distinguished from the "baby blues." Postpartum depression affects approximately 8% to 15% of all women.2,3 It may occur any time after delivery; however, most frequently it begins 2-3 weeks post delivery and may last for a year. Postpartum depression requires treatment, which usually consists of counseling and possibly medication. Postpartum psychosis affects about 1 in 1000 women. Psychosis usually occurs during the first 4 weeks of delivery. These women may have paranoia, mood swings, hallucinations, and delusions. Often, the delusions focus on the baby being demonic or dying. Postpartum psychosis requires immediate attention and hospitalization. There is a high rate of infanticide and suicide in affected mothers; therefore, it is of paramount importance that these women receive adequate intervention.

Risk factors for postpartum depression and mood disorders include personal or family history of a psychiatric disorder, unwanted pregnancy, complicated antepartum or intrapartum course, lack of social support, and other major life stressors (eg, death in the family).3,4 There is also a high risk of recurrence in subsequent pregnancies (50% to 100%).2

Screening for depression during the postpartum visit is standard of care. We routinely ask our patients several important questions: "Have you been feeling depressed? … Are you happy? … Have you been sleeping at night?" These questions, although appropriate, are probably not enough to initiate a discussion regarding the patient's state of mind. Unfortunately, many providers are pressed for time, and questions that may elicit evidence of postpartum depression are no doubt not being asked by many providers. Furthermore, many providers may be afraid of the answers they may elicit because they feel unprepared to address these sorts of problems.

Providers should not be hesitant to screen for postpartum depression. They can screen for it by using established questionnaires. Screening for postpartum depression by having the patients respond to questions from these questionnaires called depression scales ultimately may be more efficient and better ensure that appropriate interventions are initiated. There are several depression scales that can be used, including the Edinburgh Postnatal Depression Scale (EPDS), the Postpartum Depression Screening Scale (PDSS), and the Hamilton Rating Scale for Depression (HAM-D).

The EPDS is a well-validated scale used to assess the intensity of the depressive mood during the past 7 days (see Appendix A). The questions relate to mood, anxiety, guilt, and suicidal ideation.5 The scale is a 10-item self-report questionnaire; it can be completed in about 5 minutes. It has been used to screen women at risk for postpartum depression. A score of 10 or more has been shown as a useful positive screen in the postpartum period.5 Studies have shown that a score of 12 has a sensitivity of 86% and a positive predictive value of 73% for identifying women with postpartum depression.5-7 In addition, the EPDS has been validated in several countries, including Australia, Italy, The Netherlands, Portugal, and Sweden.8-11

In a study aimed to determine the feasibility of population-based screening for postpartum depression, Georgiopoulos and colleagues6 administered the EPDS to 909 women at 6 weeks postpartum in Olmsted County, Minnesota. More than 11% of women had elevated scores, indicating a positive screen for postpartum depression and the need for further evaluation. The authors concluded that using this depression scale for population-based screening was effective. However, it should be noted that the Olmsted County residents have overall high socioeconomic and educational levels; results might be rather different with population-based screening in an inner city, a region of low socioeconomic status, or an ethnically diverse community.

The PDSS is a 35-item, self-report questionnaire that can be completed in about 5 to 10 minutes.12 This scale was created specifically for postpartum women. The PDSS questions concern sleeping and eating disturbances, anxiety, insecurity, and emotional lability, feelings of guilt or shame, and suicidal ideations. It can be scored quickly. Each question is given a score from 1 through 5. A cutoff score of 80 has a 94% sensitivity and 98% specificity for major postpartum depression. A cutoff score of 60 has 91% sensitivity and 72% specificity for major/minor depression.

Other depression screening scales include the HAM-D and the Zung Self-Rating scales. However, these were not created solely for postpartum women. In addition, the HAM-D was designed to measure the severity of illness in patients already diagnosed with depression.

Ideally, providers should try to identify all depressed patients during their postpartum visit. Given the time constraints providers usually have in their practices, using a depression screening tool such as the EPDS or PDSS while the patient is waiting to see her provider may be the first step toward improving our screening for postpartum depression. Both scales have been well-validated screening tools for postpartum depression. If patients screen positive for depression, the provider must assess for possible suicidal or homicidal ideations. If the patient reports suicidal or homicidal ideations, the patient should be referred for psychiatric evaluation and possible inpatient evaluation. Patients who screen positive for depression should be referred for counseling with a social worker or psychiatrist if obstetric providers are unable to offer this service themselves.

Patients may be relieved when they find out that they screen positive for postpartum depression. It may allow a forum for further discussion of their feelings or anxieties. The questionnaire may allow both patient and doctor to feel more comfortable discussing postpartum depression. Postpartum depression not only affects the mother, but every family member. The patient and her family must be able to get the appropriate help and gain insight into this mood disorder. One source of help is Depression After Delivery, Inc. a national nonprofit organization that provides support for women with ante- and postpartum depression. It provides a professional resource list that contains the names of obstetricians, psychiatrists, psychologists, certified nurse-midwives, and social workers who have a particular interest in postpartum depression. In addition, D.A.D., Inc. provides a volunteer list of professionals who have experienced postpartum depression or psychosis themselves and are available for telephone interventions and counseling.

Screening for postpartum depression is of utmost importance. Postpartum mood disorders affect more than 10% of all mothers. Undiagnosed postpartum depression plagues both women and their families. Screening for postpartum depression allows for better identification of women who need counseling, treatment, and hospitalization. Using self-administered screening tools may aid us in diagnosing and identifying those women who may have slipped through the cracks in this era when providers are allowed limited time with their patients.

Appendix A

Edinburgh Postnatal Depression Scale (EPDS)

Taken from the British Journal of Psychiatry June 1987, Vol. 150
By JL Cox, JM Holden, R Sagovsky

The Edinburgh Postnatal Depression Scale has been developed to assist primary care health professionals to detect mothers suffering from postnatal depression; a distressing disorder more prolonged than the "blues" (which occur in the first week after delivery) but less severe than puerperal psychosis. Previous studies have shown that postnatal depression affects at least 10% of women and that many depressed mothers remain untreated. These mothers may cope with their baby and with household tasks, but their enjoyment of life is seriously affected and it is possible that there are long-term effects on the family. The EPDS was developed at health centers in Livingston and Edinburgh. It consists of ten short statements. The mother underlines which of the four possible responses is closest to how she has been feeling during the past week. Most mothers complete the scale without difficulty in less than 5 minutes. The validation study showed that mothers who scored above threshold 92.3% were likely to be suffering from a depressive illness of varying severity. Nevertheless the EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week and in doubtful cases it may be usefully repeated after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorder.

Instructions for users

  1. The mother is asked to underline the response which comes closest to how she has been feeling in the previous 7 days.
  2. All ten items must be completed.
  3. Care should be taken to avoid the possibility of the mother discussing her answers with others.
  4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.
  5. The EPDS may be used at 6-8 weeks to screen postnatal women. The child health clinic, postnatal check-up or a home visit may provide suitable opportunities for its completion.

As you have recently had a baby, we would like to know how you are feeling. Please UNDERLINE the answer which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

1. I have been able to laugh and see the funny side of things.

2. I have looked forward with enjoyment to things.

3. I have blamed myself unnecessarily when things went wrong.*

4. I have been anxious or worried for no good reason.

5. I have felt scared or panicky for not very good reason.*

6. Things have been getting on top of me.*

7. I have been so unhappy that I have had difficulty sleeping.*

8. I have felt sad or miserable.*

9. I have been so unhappy that I have been crying.*

10. The thought of harming myself has occurred to me.*

Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptoms. Items marked with an asterisk are reverse cored (i.e. 3, 2, 1, and 0). The total score is calculated by adding together the scores for each of the ten items. Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies.

References

  1. ACOG News Release. January 2002. Available at: http://www.acog.com/from_home/publications/press_releases/nr01-08-02.htm.
  2. Gabbe S, Niebyl J, Simpson J. Obstetrics: Normal and Problem Pregnancies. New York, NY: Churchill Livingstone Inc.; 1996: 705-706.
  3. Hendrick V. Postpartum and nonpostpartum depression: differences in presentation and response to pharmacologic treatment. Depression and Anxiety. 2000;11:66-72.
  4. Josefsson A, Angelsioo L, Berg G, et al. Obstetric, somatic, and demographic risk factors for postpartum depressive symptoms. Obstet Gynecol. 2002;99:223-228.
  5. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786.
  6. Georgiopoulos A, Bryan T, Yawn B, Houston M, Rummans T, Therneau T. Population-based screening for postpartum depression. Obstet Gynecol. 1999;93:653-657.
  7. Harris B, Thomas R, Johns S, Fung H. The use of rating scales to identify postnatal depression. Br J Psychiatry. 1989;154:813-817.
  8. Pop V, Komproe I, Van Son M. Characteristic of the Edinburgh Post Natal Depression Scale in The Netherlands. J Affect Disord. 1992;26:105-110.
  9. Wickberg B, Hwang C. The Edinburgh Postnatal Depression Scale: validation on a Swedish community sample. Acta Psychiatr Scand. 1996;94:181-184.
  10. Boyce P, Stubbs J, Todd A. The Edinburgh Postnatal Depression Scale: validation for an Australian sample. Aust N Z J Psychiatry. 1994;27:472-476.
  11. Benvenuti P, Ferrara M, Niccolai C, Valoriani V, Cox J. The Edinburgh Postnatal Depression Scale: validation for an Italian sample. J Affect Disord. 1999;53:137-141.
  12. Beck CT, Gable RK. Further validation of the Postpartum Depression Screening Scale. Nurs Res. 2001;50:155-164.

Jeanine K. Morris-Rush, MD, resident at Albert Einstein College of Medicine/Montefiore Medical Center; Peter S. Bernstein, MD, MPH, Assistant Professor of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, and Medical Director, Obstetrics and Gynecology, Comprehensive Family Care Center of Montefiore Medical Center, Bronx, New York.

Medscape Women's Health 7(1), 2002. Copyright © Medscape Portals, Inc.