The Causes, Diagnosis and Treatment of Postpartum Depression

1 Postpartum Depression Paper Outline I. Article 1: “Understanding the needs of women with postnatal depression” A. Definition of postpartum disorder B. PPD prevalence is approximately 13% C. Differential diagnosis-peuperal psychosis D. Diagnosis using EPDS, HQS-9 and HADS E. Treatment 1) Antidepressants 2) Non-pharmacological therapy-CBT, interpersonal psychotherapy II. Article 2: “postpartum depression: an update” A. Prevalence of PPD B. Risk factors for PPD C. Diagnosis of PPD within 6 weeks postpartum D. Occurrence of PPD in mild to severe forms E. Diagnosis by pediatrics, public health nurses and gynecologist F. Treatment based on risks/benefits III. Article 3: “postpartum depression” A. Prevalence of PPD (13%) B. Onset of PPD of up to 3 months postpartum C. Risk factors including reduced female hormones D. Referral of PPD cases characterized by suicidal thoughts E. Baby blues as differential diagnosis

2 F. Need to assess the effectiveness and safety of antidepressant treatments

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3 Postpartum Depression The article “Understanding the needs of women with postnatal depression” is a 2010 publication in the journal of Nursing Standard volume 24, issue 46 from page 47 to 56 authored by Karen Robertson. The author of this article focuses on the topic of postpartum depression with special attention to diagnosing the disorder and some of the ways a postpartum depression (PPD) patient may be helped out.

Robertson (2010) begins by defining postpartum disorder as depression that occurs after a woman has given birth thus the only difference PPD has from other depressions is the time when the depression occurs. It is also well acknowledged that the prevalence of the disorder is usually 13% but this usually ranges from 10-25%. The need to have differential diagnosis is emphasized since it is possible to misdiagnose PPD with other mental disorders such as peuperal psychosis as well as normal changes that may occur after birth. The author of this article highlights some of the symptoms that characterize PPD including lowered self confidence, increased fatigue, irritability, sleep disturbance, panic, alcohol abuse and anxiety among others. In addition, the author provides PPD assessment tools such as Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9) and Hospital Anxiety and Depression Scale (HADS). Robertson (2010) advises that normal adjustment to change should be recognized during assessment. If a PPD patient wants to breastfeed, she is advised to avoid reboxetine as a pharmacological treatment. Some of the non-pharmacological treatments that may be helpful include interpersonal psychotherapy, cognitive behavioral therapy (CBT) and non-directive counseling. This article also emphasizes on

4 the need to consider and assess the needs of the mother, infant as well as family members during treatment of PPD. Susan Hatters Friedman and Philip J. Resnick’s article “postpartum depression: an update” is published in the 2009 Women’s Health journal, volume 5, issue 3 from page 287 to 285. These authors highlight the plight of women who suffer from PPD and they stress on the need to identify the disorder as early as possible to facilitate treatment. The benefits and the risks of treating PPD using various options are discussed with adverse events of untreated PPD being infanticide, poor mother-child bond as well as reduced self care among others.

This article places the prevalence of PPD as 13%. The problem of failing to diagnose almost 50 percent of PPD cases is highlighted by Friedman and Resnick (2009). Some of the risk factors associated with PPD include a history of the disorder (personal or family), depression during pregnancy, hormonal changes, experiencing stressful situations, personality traits such as being obsessive-compulsive as well as changing roles more so for new mothers. The article highlights that PPD should be diagnosed if depression symptoms started within 2 to 6 weeks after delivery and the symptoms having lasted for at least 2 weeks. The need to differentiate normal experiences such as sleep changes in postnatal period from PPD is emphasized. The authors also note that PPD may be mild or occur in severe form and it may co-occur with anxiety symptoms.

To screen for PPD, Friedman and Resnick (2009) propose the use of EPDS and should be performed by pediatrics, obstetrics/gynecologists as well as public health nurses. Differential diagnosis includes baby blues, bipolar disorder as well as postnatal

5 psychosis. Some of the treatment options include use of antidepressants as well as non-pharmacological options such as social support, psychoeducation and psychotherapy. The authors advise on need to weigh the risks and benefits (to the mother and the infant) of treating or not treating PPD. Some prevention measures such as knowing individuals who are at risk as well as psychoeducation are highlighted but prophylactic use of antidepressants is not proven as effective.

The article “postpartum depression” is authored by Katherine L. Wisner, Barbara L. Parry and Catherine M. Piontek and published in the 2002 New England Journal of Medicine volume 347 from page 194 to199. Just like the other two articles, this article focuses on the prevalence, risk factors diagnosis (including differential diagnosis), and treatment options for PPD. In this article, the onset of PPD is said to be mainly within 4 weeks postpartum although cases of up to 3 months are considered. It is noted that PPD eventually affects the child due to reduced attachment with the mother or neglect.

Reduced female hormones such as estradiol and progesterone experienced after delivery is mentioned as a possible cause. Again, the EPDS screening scale is advised by these authors with screening questions being an alternative. Wisner et al. (2002) advise that the patient should be referred for psychiatric care if they present with risky symptoms such as suicidal ideations.

Postpartum psychosis and baby blues are highlighted as the differential diagnosis for PPD. In treating PPD, Wisner et al. (2002) advise on use of antidepressants with careful risk-benefit analysis and breastfeeding should be continued as it is often safe although this should be discussed with the mother. Prophylactic treatment should only be considered with women who are likely to experience

6 recurrence. Psychotherapy is also a suggested treatment as it reduces depression symptoms. Hormonal therapy (estradiol) has not been found to be more effective than use of antidepressants. The authors finally advise on the need to evaluate the effectiveness of antidepressants in treatment of PPD.

7 References Friedman, H. S. and Resnick, P. J. (2009). Postpartum depression: an update.

Women's Health, 5(3): 287-285.

Robertson, K. (2010). Understanding the needs of women with postnatal depression.

Nursing Standard, 24(46): 47-56.

Wisner, K. L., Parry, B. L. and Piontek, C. M. (2002). Postpartum depression. New England Journal of Medicine, 347: 194-199.