The Identification of Postpartum Depression
Scott Stuart, M.D.
Associate Professor of Psychiatry, Department of Psychiatry
University of Iowa Hospitals and Clinics
The postpartum period is one of great change for both mothers and their infants. In addition to the
obvious physical changes, psychological adjustment occurs as well. This is a crucial time for the
development of a sound bond between the infant and the mother. Disruption of this attachment,
particularly as a result of maternal depression, can have a profound effect not only the mother,
but also on her newborn and the rest of her family. For these reasons, identification and effective
treatment are paramount.
Experts agree that about one mother in ten experiences postpartum depression. Though
postpartum depression most often appears within the first three months, it can develop
at any time during the first year. Despite the high incidence of postpartum depression,
however, it remains largely unrecognized -- both by affected women and by their health
care providers. In one study, 97% of women with postpartum depression reported that
they felt there was "something wrong," but only 32% believed they were
suffering from depression. Many felt their symptoms were either not severe enough to
merit treatment or attributed them to family or child care difficulties. Most strikingly,
only 10% discussed their symptoms with a health care professional.
Primary care providers, particularly family practitioners, obstetricians, and
pediatricians, play a key role in recognizing postpartum illness. As many new mothers
will have little contact with their obstetricians after the first six weeks
postpartum, it is often the physicians caring for the newborn who have the most
contact with these women.
They need to be alert to the signs of postpartum depression. Patients should be asked about
psychological problems, or screened for postpartum depression using instruments such as the
Edinburgh Postnatal Depression Scale.
In the past, hormonal changes were believed to be the cause of postpartum depression, but recent
research has conclusively shown that this is not true. Instead, experts now see the postpartum
period as a time of psychosocial stress that may precipitate depression in some women.
This view is confirmed by evidence that links postpartum depression to such social risk factors as
being unmarried and having an unplanned pregnancy. Women from lower social classes and with lower
incomes are at higher risk for postpartum depression, as are women with poor support from their
spouses and others. Preterm birth and difficulty with pregnancy and delivery are also associated
with the illness.
A history of depression is clearly the greatest risk factor. A womans risk for postpartum
depression increases from about 10% to 25% if she has experienced depression before. If she has had
a previous episode of postpartum depression, the risk increases to almost 50%. Women who are
depressed during pregnancy also have more than a 50% chance of postpartum depression. A family
history of major depression may also increase the risk for postpartum depression.
No evidence exists for major qualitative differences between postpartum depression and other types
of depression. Recognition of postpartum depression, however, is more difficult. Many of the
changes that occur normally during the postpartum period are similar to those that signal
depression. For example, fatigue and sleep disruption may result from the demands of the newborn,
rather than from depression.
Conversely, and more important clinically, women with postpartum depression who note fatigue and
sleep problems may be ignored by their doctors, spouses, and family because the incorrect
assumption is made that this is a "normal" development rather than a symptom of
Physicians should be alert to the physical symptoms of postpartum depression while also carefully
assessing psychological symptoms. These symptoms include:
- Depressed mood
- Lack of interest or pleasure in activities
- Lack of appetite or pleasure in eating
- Sleep disruption
- Fatigue or lack of motivation
- Feelings of guilt or worthlessness
- Poor concentration
- Persistent anxiety
- Thoughts of death or suicide
New mothers who are depressed often report feelings of guilt about their ability to care for their
newborns, or report a lack of enjoyment, particularly with their children. Any tendency toward
suicidal impulse must be carefully evaluated as well. Thoughts of harm towards the newborn, though
rare, must also be assessed.
Evaluating Maternal Mental Health
Postpartum depression is a serious illness that affects women, their children, and their
families. Health care providers can easily screen their patients for this disorder by
asking directly about its symptoms. An instrument such as the Edinburgh Postnatal
Depression Scale also works well (the Maternal Mental Health Survey that is available in this issue of the newsletter is a very slightly
adapted version of the Edinburgh scale). Safe, effective treatments, including
antidepressant medications and psychotherapy, are available.
The "Edinburgh Postnatal Depression Scale" originally appeared in
"Detection of postnatal depression: The Edinburgh Postnatal Depression
Scale," by JL Cox et al. (British Journal of Psychiatry 1987, 150:782-786).
This 10-question, self-report scale has shown both reliability and validity. Each question
on the survey allows responses that earn from zero to 3 points (questions 3 and 5 through
10 are reverse scored). These points are totaled to give an overall score. A score of
12-13 is considered to indicate depression.
Though "official" diagnosis of depression according to the
Diagnostic and Statistical
Manual for Mental Disorders (DSM-IV) requires the presence of five or more symptoms over a period
of at least two weeks, clinicians should not let this stand in the way of providing appropriate
treatment for women who are depressed. The patient and physician must determine together whether
or not the patients symptoms are interfering with her ability to function. If this is the
case, regardless of how many of the symptoms are present, treatment
should be initiated.
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