Women face increased vulnerability to the onset of major depression during the childbearing years. Between 12% and 16% of women experience a major depressive episode in the postpartum period.1 Postpartum depression (PPD) can have severe and long-lasting consequences for maternal and infant functioning.2 If left untreated, it can impair maternal-infant bonding and infant attachment and can hinder the child’s cognitive and emotional development.
Based on our experience in caring for women with PPD, this article is intended to help you detect and diagnose PPD more quickly and make appropriate treatment recommendations to family physicians, obstetricians/gynecologists, and other clinicians. We will review the key risk factors for PPD, address screening and diagnostic strategies, and look at the latest evidence on psychosocial and pharmacologic treatment.
Risk factors
Key risk factors, such as a history of PPD or depression, have been identified as predictors of PPD (Table 1).3,4 In the diagnostic criteria for depression, the DSM-IV includes a specifier that states the onset of PPD must occur within 4 weeks after giving birth.5 Our clinical experience, however, indicates that PPD can occur up to 1 year after giving birth. The essential feature of major depressive disorder, according to the DSM-IV, is “a clinical course that is characterized by one or more Major Depressive Episodes” (Table 2).
PPD is often associated with comorbid anxiety disorders, which manifest in many ways. Panic attacks are often the first indication of an existing or impending depression. A small percentage of women will experience intrusive obsessional thoughts of harming their infants.
ANDREA YATES: WARNING SIGNS WERE MISSED
Andrea Yates, 37, of Harris County, Texas, was convicted of two counts of murder in the June 2001 bathtub drownings of her five children. The jury deliberated less than 4 hours to reach the verdict March 12. The next day, she was sentenced to life in prison. She had pleaded not guilty by reason of insanity.
It is not known why Mrs. Yates discontinued her antipsychotic medication a few weeks prior to this tragedy and why those around her did not heed the numerous warning signs of her mental illness.
Roughly 30% of women with postpartum depression experience thoughts of suicide or infanticide/homicide. Mrs. Yates showed evidence of such thoughts shortly after the birth of her first child, but she did not receive psychiatric care until her third child was born. Although she was hospitalized several times, no follow-up psychiatric care was provided. It was reported that she twice attempted suicide.
During the trial, defense attorneys presented testimony by psychiatrists that Mrs. Yates was suffering postpartum psychosis and schizoaffective disorder. Her severe illness produced the delusional belief that killing the children would save them from eternal damnation. Prosecutors convinced the jury that Mrs. Yates, although ill, was capable of distinguishing right from wrong at the time of the slayings and therefore did not meet the strict Texas standard for insanity.
Mental illness during pregnancy or the postpartum period is poorly understood by new mothers and their families. The verdict and sentence in this case represent an enormous step backward.
The media treatment of Andrea Yates and her imprisonment—rather than hospitalization for proper treatment of her mental illness—may deter mothers from telling their physicians about any negative feelings they may be experiencing. As a result, women who could benefit from treatment of depressive illness will not be identified, and they and their children will be at risk.
Shaila Misri, MD, FRCPC
Xanthoula Kostaras, BSc
Table 1
RISK FACTORS FOR POSTPARTUM DEPRESSION
| Major factors | Contributing factors |
|---|---|
|
|
Screening and diagnosis
Many women will not report depressive symptoms to their primary care physicians or obstetricians during the routine postpartum visit. This reticence by mothers to volunteer any negative information about themselves may be due to the brevity of the typical postpartum visit or its usual focus on the welfare of the infant.
A recent study of 391 outpatients in an obstetrical practice demonstrates the value of using a screening instrument to identify possible PPD cases during the 6-week follow-up visit. When the women were screened with the standardized Edinburgh Postnatal Depression Scale (EPDS), the rate of detection of PPD was 35.4%, whereas the rate of spontaneous detection was 6.3%.6
The EPDS (Box 1), a 10-item self-report questionnaire developed by Cox and colleagues, is used specifically to detect PPD.7 A minimum score of 12 or 13 warrants a diagnosis of PPD. The EPDS can be used as a screening tool at 6 to 8 weeks postpartum and can be repeated over several visits to track symptoms. This tool has been validated, computerized, and translated into more than 12 languages and can be copied and used free of charge.