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The Identification of Postpartum Depression 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. Postpartum Depression
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 woman’s 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 depression. Physicians should be alert to the physical symptoms of postpartum depression while also carefully assessing psychological symptoms. These symptoms include:
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.
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 patient’s 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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