Psychiatric / Mental Health

Postpartum depression: Don’t let patients suffer in silence

This might come as a surprise, but postpartum depression (PPD) is the number-one complication of childbearing. Experts estimate it strikes at least one in 10 women, with approximately 400,000 new cases each year in the United States.

PPD doesn’t discriminate by age, race, ethnicity, or income. It affects our sisters, mothers, wives, daughters, coworkers, neighbors, and friends. Celebrities, including Brooke Shields and Gwyneth Paltrow, have described their PPD experiences, helping to raise awareness of the disorder among the general public.

Anyone who has had a baby is at risk for PPD. The good news is that detected and acknowledged, the disorder can be treated effectively. Women don’t need to suffer in silence. Help is available, and nurses can guide them to it.

Types of postpartum mood disorders

PPD is a quiet, unending epidemic that plays out in homes all over America, punctuated by occasional dramatic cases that make headlines. Actually, PPD is one disorder in a broad spectrum of adjustment disorders that arise during the postpartum period, which range from the common, self-limiting postpartum blues (“baby blues”) lasting just a few days or weeks, to the rare but severe postpartum psychosis.

PPD is distinctly different from both the “baby blues” and psychosis. Generally, it’s defined as severe depression lasting beyond 4 to 6 weeks during the weeks or months after delivery. (See the table below).

Is it baby blues or something more serious?

Use this table to help differentiate baby blues from a more serious type of postpartum disorder.


Characteristic ”Baby blues” Postpartum depression
Onset 1 week after delivery 2 to 12 months after delivery
Duration Resolves spontaneously within 7 to 10 days Weeks, months, or longer
Emotional Features
  • Crying
  • Feelings of sadness, possibly alternating with happy feelings
  • Sense of being overwhelmed
  • Crying
  • Feeling of overwhelming sadness, helplessness, and worthlessness
  • Feeling of loss of control
  • Intensive or excessive worry
  • Forgetfulness, Inability to focus or concentrate
  • Possible anxiety, panic attacks, and obsessive-compulsive behaviors
  • Feeling of disconnected from baby
Sleep Pattern Feels tired, but can sleep when baby sleeps Feel tired, but can’t fall asleep within 30 minutes of retiring or wakes up in middle of night and can’t fall back to sleep
Health care Resolves spontaneously without intervention Makes multiple visits to healthcare providers for self or baby
Danger Low risk
  • May be suicidal
  • May have thoughts of harming self or baby
Nursing intervention
  • Teaching patient about PPD symptoms, including need to seek help if symptoms don’t resolve.
  • Encourage patient to ask support persons for help with baby, housework, and meals.
  • Teach patient how to maximize sleep.
  • Refer patient for psychological evaluation by primary care provider, psychologist, psychiatrist, psychiatric RN, counselor or social worker (particularly one trained in special needs of women with PPD.
  • Reassure patient she’s not alone and that what she’s feeling is real.
  • Encourage patient to ask for help with baby, housework, and meals.
  • Teach patient how to maximize sleep.
  • Refer patient to public health nurse to assess baby in home and provide follow-up care, as appropriate.

 

Recognizing PPD

Key signs and symptoms of PPD include sadness, excessive worry, feeling disconnected from the baby, forgetfulness, inability to focus or concentrate, anger, fear, guilt, grief, inability to fall asleep, waking during the night and having trouble falling back to sleep, exhaustion, and multiple physical complaints. Some women report they feel numb or that they’re in a fog, or describe a sinking feeling or a sense that they can’t “snap out of it.” Some may express the feeling that “if this is what motherhood is like, I want out.” Some women may feel ashamed or embarrassed about these feelings.

Anxiety commonly accompanies PPD, with some women experiencing panic attacks or obsessive-compulsive behaviors. In other cases, PPD patients have recurring symptoms (similar to those seen in post-traumatic stress disorder) related to trauma during delivery. Typically, symptoms arise within 4 weeks of delivery but may be delayed for up to 12 months postpartum. PPD prevalence appears to peak around 3 months postpartum.

It’s hard to predict who will develop PPD. Factors that may increase risk include:

  • history of depression before or during pregnancy
  • preexisting anxiety or mental illness
  • lack of social support
  • childcare stress
  • life stress
  • low self-esteem
  • fatigue
  • difficult infant temperament
  • single marital status
  • unplanned or unwanted pregnancy
  • young age.

But even for professionals aware of these risk factors, PPD can be challenging to predict—and to prevent. Research continues in this area. Fortunately, free screening tools exist to help detect PPD signs and symptoms. These simple tools can be used with patients at any time during the first year after delivery.

PPD screening

Although anyone can screen patients for PPD, professionals who work in emergency departments, family practice, pediatrics, gynecology, or other settings many where women and children are treated should be especially alert for PPD signs and symptoms. Some states, such as New Jersey, have begun to mandate PPD screening.

Making frequent visits to healthcare providers is a common sign in women who’ve given birth during the past year. Nurses need to ask about postpartum depression whenever we have contact with patients who’ve recently given birth—even though it may be a difficult conversation to initiate. It’s important to ask the right questions, and keep asking them, to help patients with PPD get appropriate treatment.

Even if you have time to ask just two questions, ask the two recommended by the U.S. Preventive Services Task Force (USPSTF) for primary-care settings:

  • “Over the past 2 weeks, have you felt down, depressed, or hopeless?”
  • “Over the past 2 weeks, have you had little interest or pleasure in doing things?” If the patient says “yes”, explore further by asking, “Have you felt this way for several days, more than half the days, or nearly every day?”

Another widely used screening tool is the Edinburgh Postnatal Depression Scale (EPDS), a 10-question tool that has been well-tested, validated, and translated into many languages. It can be completed by the patient in about 5 minutes and requires no special preparation or training. The EPDS is available at www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.

Although these screening tools can indicate if a woman is living with many of the symptoms of PPD, be aware that they’re not diagnostic. Symptomatic patients need further clinical assessment.

Offering a referral

If you suspect PPD, offering the patient a referral is the first step. Urge her to contact her primary care provider, or refer her to a local psychiatrist, psychologist, psychiatric nurse, family therapist, or licensed clinical social worker. Keep in mind that many women with PPD are too overwhelmed, exhausted, or scared to make that first phone call without help. So be prepared to help them make the call if necessary. Know, too, that PPD support groups and national hotlines exist. (See the box below.)

Resources for patients and families coping with postpartum depressionPostpartum Support International
http://postpartum.net/PSI Postpartum Depression Hotline
1-800-944-4PPD (4773)Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends
http://mchb.hrsa.gov/pregnancyandbeyond/depression/NIH Medline Plus: Postpartum Depression
http://www.nlm.nih.gov/medlineplus/postpartumdepression.htmlNational Women’s Health Information Center: Depression During and After Pregnancy
http://www.womenshealth.gov/faq/depression-pregnancy.cfmPostpartum Depression Support Group
http://mdao.v-cc.com/support/default.aspx

Managing PPD

Many treatments are available for PPD, and with appropriate intervention most women make a full recovery. The sooner treatment starts, the sooner they’ll begin to feel better.

Treatment options depend partly on patient preference. They include traditional talk therapy, antidepressant drugs, hormone therapy, and alternative therapies. In many cases, a stepped or combined approach is used. Some women may refuse drug treatment due to concerns about medications, so professionals may offer talk therapy first; this may involve peer support, group or individual counseling, cognitive behavioral therapy, or interpersonal psychotherapy. Patients can participate in this process in person, over the telephone, or even online. Merely communicating with others who have been through PPD can be extremely helpful.

If medication is warranted, a selective serotonin reuptake inhibitor may be prescribed. Sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and fluoxetine (Prozac) are some of the more commonly used drugs to treat PPD. Nortriptyline, a tricyclic antidepressant, may be used in some cases. Certain antidepressants are considered safer than others, but none is contraindicated in breastfeeding women. Other treatment options include natural remedies, such as herbals, fish oils, and dietary supplements.

These interventions can improve the patient’s quality of life, and research suggests that treating the mother’s depression improves her child’s well-being, too. Depression affects the whole family, so by identifying women with PPD symptoms through screening, we can also provide support for partners and other family members.

Breaking the silence

We need more research on PPD, along with greater clinical and public awareness. PPD screening should become part of routine nursing care for all postpartum women, just as we screen for other common medical conditions. As nurses, we have the privilege of providing a safe place for women to share their suffering and enable them to get the treatment they need. Women with PPD especially need our help. Tell them they’re not alone and not to blame, that PPD happens to many women, and that help is available. There’s no need to suffer in silence any more.

Emily E. Drake is an associate professor at the University of Virginia School of Nursing in Charlottesville. Gayle Coolidge is a registered nurse at the University of Virginia Health Sciences Center in Charlottesville.

References

Beck CT, Indman P. The many faces of postpartum depression. JOGNN. 2005;34(5):569-576.

Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786.

Dennis C, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth. 2006;33(4):323-331.

Dennis C-L, Hodnett ED. Psychosocial and psychological interventions for treating postpartum depression. Cochrane Database of Systematic Reviews. 2007;4;Art. No.: CD006116. DOI: 10.1002/14651858.CD006116.pub2.

Earls MF, Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010 Nov;126(5):1032-1039. http://pediatrics.aappublications.org/cgi/content/abstract/126/5/1032. Accessed November 26, 2010.

Gaynes B, Gavin N, Melzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Agency for Healthcare Research and Quality. February 2005. Evidence Report/Technology Assessment: Number 119:1-8. www.ahrq.gov/clinic/epcsums/peridepsum.pdf Accessed November 9, 2010.

Hale TW. Medications and Mothers’ Milk: A Manual of Lactational Pharmacology. (13th ed.). Amarillo, Texas: Pharmasoft Medical Publishing; 2008.

Levy LB, O’Hara MW. Psychotherapeutic interventions for depressed, low-income women: a review of the literature. Clin Psychol Rev. 2010 Dec; 30(8): 934-950.

Olson AL, Dietrich AJ, Prazar G, Hurley J. Brief maternal depression screening at well-child visits. Pediatrics. 2006;118(1):207-216.

Sit DKY, Wisner KL. Identification of postpartum depression. Clin Obstet Gynecol. 2009; 52(3):456-468.

This article was supported in part by NIH-NINR grant P20NR009009, Rural Health Care Research Center at the University of Virginia School of Nursing.

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One thought on “Postpartum depression: Don’t let patients suffer in silence”

  1. Becky says:

    The recommendation for screening for postpartum depression by all healthcare providers is so important. Postpartum depression not only affects women but can lead to severe adverse effects in their children. The American Academy of Pediatrics (AAP) asserts that infants who live in a neglectful or depressed setting are likely to show delays in development and impaired social interaction.

    Despite a strong recommendation from the AAP that all mom’s be screened for PPD at well child visits, the overall rate for screening remains low. A study in 2014 showed only 1/4 of pediatricians screened formally or informally for maternal depression. Many healthcare providers avoid screening due to a lack of resources for following up on a positive screen. Having a plan for referral or a list of community resources for patients is important. Healthcare providers have the opportunity to positively impact women by taking the time to ask.

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