PostpartumDepression

Donna E.Stewart, C.M., M.D., and Simone Vigod M. 

New England Journal of Medicine

This is a case vignette of a young single mother of  a 3 month ago who presents with depressive symptoms that have lasted for 2 months. She has a previous history of depression and postpartum depression. She is not suicidal or psychotic but feels that she cannot cope. Talks about postpartum depression, the risk factors, screening and diagnosis, and treatment. 

What is it?:

• Most common postnatal Neuropsychiatric disorder in which a patient has a major depressive episode “with peripartum onset if onset of mood symptoms occur during pregnancy or within 4 weeks following delivery”. In clinical practice postpartum depression is defined as depression that occurs within up to 12 months after childbirth. 
• Symptoms include sleep disturbance, anxiety, irritability, and a feeling of being overwhelmed as well as an obsessional preoccupation with the baby’s health and feeding. 

• iT CAN BE CONFUSED WITH Baby blues WHICH CAN OCCUR IN 70% of new women have mild depressive symptoms, which happens between 2 and 5 days after delivery and include weepiness, sadness, labile mood, irritability, and anxiety.These symptoms do not impair function or include psychotic symptoms and it may resolve spontaneously within 2 weeks or progress to postpartum depression. 

Risk factors:

• Previous history of MDD, PPD, life stressors, poor social support increases risk of PPD. Women who have untreated depression during pregnancy have a 7 times greater risk than those without. So providing supportive and psychological care such as home visits, telephone-based peer support or interpersonal therapy would help lower the risk of postpartum depression.

Screening and diagnosis 

• Clinical inquiry about mood during postpartum visits. Screening should be done for all postpartum women with administration of the 10-item Postnatal Depression Scale (EPDS), PHQ-2, if answered yes then PHQ-9. Any positive findings should lead to a comprehensive clinical interview. 
• Pay special attention to personal or family history of depression, postpartum psychosis, or bipolar disorder. 
• To diagnose patients with PPD they must have symptoms of MDD during pregnancy or within 12 months of pregnancy. 
• Criteria for major depressive episodes includes, at least 5 symptoms present for at least 2 weeks, for most of nearly every day. Of which one symptom must include depressed mood, loss of  interest in activities they enjoyed  before. Other symptoms include, sleep disturbances, changes in appetite, fatigue. but these symptoms would cause significant distress or impairment in social, occupational or other areas of functions. 

How is it treated?:

• So, the Treatment varies according to the severity of the woman’s symptoms and her functional status. 
• Psychotherapy: mild depression may be addressed with psychosocial strategies, which includes peer support, counseling. So Cognitive behavior therapy or interpersonal therapy can be used for mild to moderate postpartum depression. 
• CBT: focus on changing maladaptive thought patterns, or behaviors. 
• Interpersonal therapy focuses on interpersonal relationships to help with transition to parenthood.  
• Pharmacotherapy: Recommended when symptoms of postpartum depression does not resolve with psychological treatment alone and for severe symptoms that require rapid treatment. Treatment with SSRIs (fluoxetine or citalopram) is considered the first line with combination of psychotherapy. Sertraline is favored for breastfeeding women. SNRIs or mirtazapine can be used if SSRIs are ineffective.  
• Pharmacotherapy is continued for at least 6 to 12 months after complete remission of depressive   to reduce risk of relapse. 
• Hospitalization, ECT or both may be required for severe cases that are unresponsive to drug therapy or when active suicidal intent or psychosis is present. 

The woman described in the vignette has a history of untreated depression and criteria for major depression with peripartum onset. NO suicidal or psychotic symptoms psychotherapy would be provided. If patient wanted medication then favor sertraline, especially given the availability of reassuring data regarding its safety during lactation;a dose of 50 mg daily,