A new screening tool, the Postpartum Depression Screening Scale (PDSS), was recently developed and validated by Beck and colleagues to help clinicians identify and respond to PPD as early as possible.8 Depressive symptoms are rated on a 5-point scale, and the total score is used to determine overall severity of depressive symptoms. Higher PDSS scores correspond to increasing severity of symptoms and indicate that the patient should be referred for additional evaluation. The PDSS is published by Western Psychological Services (www.wpspublish.com).
Psychosis in PPD
Psychotic depression in the postpartum period is sometimes associated with chronic mood disorders, especially untreated depression. The most prevalent psychotic features include paranoid delusions that incorporate the newborn. Hallucinations are rare. Psychotic depression places the postpartum patient at a heightened risk for suicide and/or infanticide and is considered a medical emergency that requires immediate hospitalization and treatment to ensure the safety of the infant and the ill mother (see “Andrea Yates: Warning signs were ignored,”).
If a patient with psychotic PPD is experiencing delusions centered on harming her infant, a family member or members should assume responsibility for the child’s care, and the patient should not be left alone with the infant. When the mother is hospitalized, visitation between the mother and infant should be restricted, particularly if the infant’s presence precipitates anxiety in the mother. The goal of hospitalization is to achieve symptom remission and stability in the mother so that bonding and attachment can occur. Maternal-infant bonding is difficult, if not impossible, if the mother is out of touch with reality.
Treating mild to moderate PPD
Psychosocial therapies are first-line treatment for mild-to-moderate PPD symptoms or when a patient refuses pharmacotherapy. These therapies include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), group therapy, family and/or marital therapy, supportive psychotherapy, and peer support groups. Psychosocial therapies also should be used as adjunctive treatments to pharmacotherapy.
Table 2
DSM-IV CRITERIA FOR A MAJOR DEPRESSIVE EPISODE
|
CBT. A preliminary study examining short-term cognitive-behavioral counseling for postpartum depressed women reported that participants who received six CBT sessions showed the same degree of improvement in functioning as did a group receiving fluoxetine. Both groups showed greatly improved functioning when compared with a group that received a placebo.9
IPT. In pregnant and postpartum women, the focus of IPT is on role transitions and the acquisition of skills applicable to motherhood. Preliminary studies of IPT in pregnant and postpartum women have shown encouraging results.10 A recent controlled study of 99 women provided additional evidence that IPT helps decrease depressive symptoms and promote social adjustment in women with moderate PPD.11
Group therapy. One of the most valuable benefits of group therapy in PPD treatment is that it may help women who are feeling socially isolated to increase their support networks. Several psychosocial therapy methods may be adapted to a group model, including interpersonal and supportive psychotherapy.
Family and marital therapy. The roles of the partner and family are critical to treating women with mood and anxiety disorders during pregnancy or the postpartum period. A recent study found that postpartum depressed women recover more rapidly and appreciate their partners’ contribution to the relationship more when the partner is supportive.12
Supportive psychotherapy involves offering patients and their families support, reassurance, and psychoeducation. This type of therapy is used to augment other psychosocial interventions and/or pharmacotherapy. In some cases, supportive therapy may be the only treatment a woman receives if her depressive symptoms are too severe for her to engage in CBT or IPT and she refuses pharmacotherapy. Then supportive psychotherapy is used to monitor her mental state.
Peer-support groups. Several groups formed by consumers and health care providers offer support and education to women with reproductive-associated mood and anxiety disorders. (See “Related resources,”).
Pharmacologic treatment
Pharmacotherapy is indicated in women with moderate-to-severe symptoms who do not respond to psychosocial treatment alone. Because all psychotropic medications are excreted in breast milk and passed on to the nursing infant, one must weigh the potential risks of the infant’s exposure to medication against the risks of untreated maternal depression.