An FP’s guide to identifying—and treating—postpartum depression

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doi:doi: 10.12788/jfp.0510

Behavioral Health

An FP’s guide to identifying—and treating—postpartum depression

J Fam Pract. 2022 November;71(9):403-406 | doi: 10.12788/jfp.0510

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References

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2. Banti S, Mauri M, Oppo A, et al. From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new onset of depression. Results from the Perinatal Depression–Research & Screening Unit study. Compr Psychiatry. 2011;52:343-351. doi: 10.1016/j.comppsych.2010.08.003

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4. Altemus M, Neeb CC, Davis A, et al. Phenotypic differences between pregnancy-onset and postpartum-onset major depressive disorder. J Clin Psychiatry. 2012;73:e1485-e1491. doi: 10.4088/JCP.12m07693

5. Wilson LM, Reid AJ, Midmer DK, et al. Antenatal psychosocial risk factors associated with adverse postpartum family outcomes. CMAJ. 1996;154:785-799.

6. Robertson E, Grace S, Wallington T, et al. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry. 2004;26:289-295. doi: 10.1016/j.genhosppsych.2004.02.006

7. Beck CT. Predictors of postpartum depression: an update. Nurs Res. 2001;50:275-285. doi: 10.1097/00006199-200109000-00004

8. Bell AF, E Andersson. The birth experience and women’s postnatal depression: a systematic review. Midwifery. 2016;39:112-123. doi: 10.1016/j.midw.2016.04.014

9. Palladino CL, Singh V, Campbell J, et al. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol. 2011;118:1056-1063. doi: 10.1097/AOG.0b013e31823294da

10. Ko JY, Rockhill KM, Tong VT, et al. Trends in postpartum depressive symptoms — 27 States, 2004, 2008, and 2012. MMWR Morb Mortal Wkly Rep. 2017;66:153-158. doi: 10.15585/mmwr.mm6606a1

11. Rafferty J, Mattson G, Earls MF, et al. Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics. 2019;143:e20183260. doi: 10.1542/peds.2018-3260

12. Lovejoy MC, Graczyk PA, O’Hare E, et al. Maternal depression and parenting behavior: a meta-analytic review. Clin Psychol Rev. 2000;20:561-592. doi: 10.1016/s0272-7358(98)00100-7

13. Curry SJ, Krist AH, Owens DK, et al. Interventions to prevent perinatal depression: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;321:580-587. doi: 10.1001/jama.2019.0007

14. Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for depression in adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315:380-387. doi: 10.1001/jama.2015.18392

15. ACOG. Screening for perinatal depression. 2018. Accessed October 5, 2022. www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression

16. Yawn BP, Bertram S, Kurland M, et al. Repeated depression screening during the first postpartum year. Ann Fam Med. 2015;13:228-234. doi: 10.1370/afm.1777

17. van der Zee-van den Berg AI, Boere-Boonekamp MM, Groothuis-Oudshoorn CGM, et al. Post-up study: postpartum depression screening in well-child care and maternal outcomes. Pediatrics. 2017;140:e20170110. doi: 10.1542/peds.2017-0110

18. Rosener SE, Barr WB, Frayne DJ, et al. Interconception care for mothers during well-child visits with family physicians: an IMPLICIT Network study. Ann Fam Med. 2016;14:350-355. doi: 10.1370/afm.1933

19. Nonacs R, Cohen LS. Postpartum mood disorders: diagnosis and treatment guidelines. J Clin Psychiatry. 1998;59(suppl 2):34-40.

20. ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstet Gynecol. 2018;131:e140-e150. doi: 10.1097/AOG.0000000000002633

21. Langan R, Goodbred AJ. Identification and management of peripartum depression. Am Fam Physician. 2016;93:852-858.

22. Sharma V, Sharma P. Postpartum depression: diagnostic and treatment issues. J Obstet Gynaecol Can. 2012;34:436-442. doi: 10.1016/S1701-2163(16)35240-9

23. Owara AH, Carabin H, Reese J, et al. Summary diagnostic validity of commonly used maternal major depression disorder case finding instruments in the United States: a meta-analysis. J Affect Disord. 2016;205:335-343. doi: 10.1016/j.jad.2016.08.014

24. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington D.C.: 2013:160.

25. Mandelli L, Souery D, Bartova L, et al. Bipolar II disorder as a risk factor for postpartum depression. J Affect Disord. 2016;204:54-58. doi:10.1016/j.jad.2016.06.025

26. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008;111:1001-1020. doi: 10.1097/AOG.0b013e31816fd910

27. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875. doi: 10.1176/appi.ajp.157.11.1873

28. Curry SJ, Krist AH, Owens DK, et al. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force Final Recommendation Statement. JAMA. 2018;320:1678-1687. doi: 10.1001/jama.2018.14741

29. ACOG Committee Opinion No. 518: Intimate partner violence. Obstet Gynecol. 2012;119:412-417. doi: 10.1097/AOG.0b013e318249ff74

30. Thyroid Disease in Pregnancy: ACOG Practice Bulletin, Number 223. Obstet Gynecol. 2020;135:e261-e274. doi: 10.1097/AOG.0000000000003893

31. Wassef A, Nguyen QD, St-André M. Anaemia and depletion of iron stores as risk factors for postpartum depression: a literature review. J Psychosom Obstet Gynaecol. 2019;40:19-28. doi: 10.1080/0167482X.2018.1427725

32. Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician. 2010;82:926-933.

33. Nillni YI, Mehralizade A, Mayer L, et al. Treatment of depression, anxiety, and trauma-related disorders during the perinatal period: a systematic review. Clin Psychol Rev. 2018;66:136-148. doi: 10.1016/j.cpr.2018.06.004

34. Daley AJ, Macarthur C, Winter H. The role of exercise in treating postpartum depression: a review of the literature. J Midwifery Womens Health. 2007;52:56-62. doi: 10.1016/j.jmwh.2006.08.017

35. Misri S, Kostaras X, Fox D, et al. The impact of partner support in the treatment of postpartum depression. Can J Psychiatry. 2000;45:554-558. doi: 10.1177/070674370004500607

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Is it “the blues” or something else? Diagnosing PPD

Many new mothers experience postpartum blues, which manifest as tearfulness, insomnia, irritability, and anxiety. The postpartum blues, however, don’t meet the criteria for major depressive disorder and typically resolve within 14 days of delivery.^19-21 On the other end of the spectrum is postpartum psychosis, which is severe and rare, and can also affect new mothers.

Screening for PPD. The most commonly used screening tool for PPD is the Edinburgh Postnatal Depression Scale (EPDS 10), a free 10-item instrument scored out of 30 possible points, with any score ≥ 13 suggesting PPD.²² The EPDS 10 has a sensitivity of 74% and specificity of 97% for the diagnosis of PPD.²³ Other screening options include the Beck Depression Inventory II (BDI-II) and the Patient Health Questionnaire 9 (PHQ-9). The 21-item BDI-II takes longer to perform and is less sensitive (57%) than the EPDS.¹ The PHQ-9, which asks about some symptoms common to the postpartum period (including sleep changes), is less specific than the EPDS (sensitivity, 75%; specificity, 90%).¹ The EPDS also includes screening questions about anxiety.¹

A positive depression screen, or any positive response to a question on suicidal ideation, should be followed up for confirmation using the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) criteria for major depressive disorder with peripartum onset.²⁴ Women with PPD should also be asked about current or prior symptoms of bipolar disorder or mania.²⁵ Up to 67% of women with bipolar disorder may relapse postpartum, and they also have an elevated risk of postpartum psychosis.²⁶ The Mood Disorder Questionnaire is a useful tool if a concern for bipolar depression arises.²⁷

Refer any woman in whom bipolar depression is a concern to a clinician experienced with its management. The presence of auditory or visual hallucinations should also be assessed as indicators of postpartum psychosis. Active suicidal or homicidal ideation and postpartum psychosis all require emergent psychiatric care.^21,22 Intimate partner violence may also exist or escalate in the postpartum period and may exacerbate PPD. Both ACOG and the USPSTF recommend screening postpartum women for intimate partner violence.^28,29

Also consider possible medical causes of PPD symptoms. Hypothyroidism in the postpartum period may manifest with some similar symptoms to PPD and is commonly underdiagnosed.^22,30 Women with postpartum anemia and low ferritin stores also have a higher likelihood of PPD (odds ratio, 1.7-4.64), and postpartum iron supplementation may reduce this risk (number needed to treat = 4 in at least 1 randomized controlled trial).³¹ When anemia is present, ensure that it is properly treated.

Continue to: Steps you can take to manage pPD