Bipolar disorder in postpartum women - Epidemiology, clinical features, assessment, and...

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Official reprint from UpToDatewww.uptodate.com 2013 UpToDate

Author Victoria Hendrick, MD

Section Editor Paul Keck, MD

Deputy Editor David Solomon, MD

Bipolar disorder in postpartum women: Epidemiology, clinical features, assessment, and diagnosis

Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Oct 2013. | This topic last updated: Jun 14, 2013.

INTRODUCTION A large, nationally representative survey of the United States general population estimatedthat among postpartum women, the 12-month prevalence of bipolar disorder was 2.9 percent [ 1]. Manypostpartum bipolar patients suffer acute mood episodes [ 2-4 ], and the risk of episodes in female bipolar patientsmay be greater during the puerperium than at other times [ 2,5 ].

This topic reviews the epidemiology, pathogenesis, clinical features, assessment, and diagnosis of postpartumbipolar mood episodes. Treatment of postpartum bipolar disorder, postpartum psychosis, and postpartum unipolar major depression are discussed separately. (See "Bipolar disorder in postpartum women: Treatment" and"Treatment of postpartum psychosis" and "Postpartum blues and depression" .)

DEFINITIONS Bipolar disorder is a mood disorder that is characterized by episodes of mania ( table 1 ),hypomania ( table 2 ), and major depression ( table 3 ), as well as mixed episodes (major depression concurrent withmania) [ 6]. The subtypes of bipolar disorder include bipolar I and bipolar II . Patients with bipolar I disorder experience manic and mixed episodes, and nearly always experience major depressive and hypomanic episodes.Bipolar II disorder is marked by at least one hypomanic episode, at least one major depressive episode, and theabsence of manic and mixed episodes. Additional information about the clinical features and diagnosis of bipolar disorder is discussed separately. (See "Bipolar disorder in adults: Clinical features", section on 'Clinicalpresentation' and "Bipolar disorder in adults: Assessment and diagnosis", section on 'Diagnosis' .)

Onset of postpartum bipolar mood episodes occurs within a limited time period following birth of a live child.However, there is no established cut-off that separates postpartum-onset episodes from subsequentnonpostpartum episodes [ 7]; definitions of the puerperium include the following:

For episodes with postpartum onset, the American Psychiatric Association's Diagnostic and StatisticalManual, Fourth Edition, Text Revision (DSM-IV-TR) requires onset of the episode within four weeks of childbirth [ 6]

For episodes that are associated with the puerperium, the World Health Organization's InternationalClassification of Diseases-10th Revision (ICD-10) requires onset of the episode within six weeks of delivery[8]

Other definitions of the puerperium range from the first 3 to 12 months following a live birth [ 2,7,9 ]

Postpartum bipolar mood episodes are often referred to as postpartum psychosis or puerperal psychosis,although neither term is a formal diagnosis in DSM-IV-TR or ICD-10 [ 6,8 ].

EPIDEMIOLOGY The risk of acute bipolar mood episodes may be greater in the puerperium than at other times. A retrospective study of 621 bipolar patients found that mood episodes occurred significantly more often inthe postpartum period than during pregnancy (52 versus 23 percent of patients) [ 2]. In a second retrospectivestudy, 20 gravid and 25 nongravid bipolar patients discontinued maintenance treatment and remained stable for 40weeks; recurrence during weeks 41 to 64 occurred in significantly more postpartum patients than nongravidpatients (70 versus 24 percent) [ 5].

lar disorder in postpartum women: Epidemiology, clinical features,... http://www.uptodate.com/contents/bipolar-disorder-in-postpartum-wom...

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General population A study of nationwide Swedish birth and hospitalization registries found that the incidenceof hospitalization for a postpartum bipolar mood episode was 0.03 percent [ 10 ]. However, this figure probablyoverestimates the incidence because it appears that the bipolar group included patients with unipolar depression[11 ].

Clinical samples Reviews of retrospective studies suggest that among bipolar patients, mood episodes occur after 25 to 50 percent of deliveries [ 12-15 ]; variations in rates between studies are probably due in part todifferences in how episodes were defined, with lower rates observed in studies that included only more severe

episodes [ 16 ].

Factors associated with an increased risk of postpartum bipolar mood episodes include:

Lack of maintenance pharmacotherapy preceding or following delivery [ 5,17 ]Prenatal mood symptoms and episodes [ 2,10,18,19 ]Younger age [ 12,20 ]Unplanned pregnancy [ 12 ]Primiparity [ 20 ]History of previous postpartum mood episodes [ 21,22 ]Family history of mood disorder or postpartum psychosis [ 21-23 ]

Onset of bipolar disorder may occur during the puerperium [ 18 ].

Psychotic episodes Bipolar patients appear to be at increased risk for postpartum psychosis (eg,delusions and hallucinations) [ 13,15,17,24 ].While the estimated rate of puerperal psychosis in the generalpopulation is 1 to 2 per 1000 live births [ 25,26 ], one study found the rate in bipolar women was 260 per 1000deliveries [ 21 ]. Other studies have found that psychosis occurs in approximately 10 to 50 percent of postpartumbipolar patients [ 27,28 ].

In addition, many patients who present with postpartum psychosis are ultimately diagnosed with bipolar disorder [15,24,28-30 ]. As an example, two retrospective studies of patients admitted for postpartum psychosis (N = 119and 50) found that the underlying diagnosis was bipolar disorder in 31 and 42 percent [ 31,32 ].

Factors associated with an increased risk of postpartum psychosis in bipolar patients include:

Delivery complications (eg, breech presentation, fetal distress, and cord accidents) [ 33 ]Prenatal mood episodes [ 19 ]Prenatal obstetric complications (eg, hyperemesis, preeclampsia, and premature contractions) [ 19 ]Primiparity [ 33 ]History of prior puerperal psychosis [ 13,34 ]Early age of onset of bipolar disorder [ 19 ]Family history of bipolar disorder or postpartum psychosis [ 21,34,35 ]

Additional information about postpartum psychosis is discussed separately. (See "Postpartum psychosis:

Epidemiology, clinical manifestations, and assessment" and "Treatment of postpartum psychosis" .)PATHOGENESIS The etiology of postpartum bipolar mood episodes is not known. Possible causes includedecreases in estrogen and progesterone, decreased or erratic sleep, increased stress associated with caring for the newborn, and social issues (eg, relationship or financial problems) [ 27,29,36-38 ]. In addition, genetic effectsmay possibly render patients vulnerable to episodes [ 20,39,40 ]:

A family study of bipolar disorder found that postpartum relapse occurred in significantly more patients witha positive family history of postpartum mania or psychosis (N = 27) compared with patients who had nosuch history (N = 125) (74 versus 30 percent) [ 21 ]

A family study of bipolar disorder found that postpartum mood symptoms and episodes occurred insignificantly more patients with a positive family history of postpartum symptoms (N = 69) compared withpatients who had no such history (N = 234) (30 versus 15 percent) [ 41 ]

A genome-wide linkage study found an area on chromosome 16 associated with susceptibility to postpartum


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bipolar mood episodes [ 42 ]

CLINICAL MANIFESTATION Bipolar disorder is characterized by episodes of major depression ( table 3 ), mania(table 1 ), and hypomania ( table 2 ), as well as mixed episodes (major depression concurrent with mania or hypomania) [ 6]. The most common psychopathology among postpartum bipolar patients is major depression[18,43-45 ]. A retrospective study of 1120 pregnancies in bipolar patients found the following rates of postpartummood episodes [ 2]:

Major depression 25 percent of pregnanciesMixed (depression concurrent with mania or hypomania) 4 percentMania 3 percentHypomania 2 percent

These findings are consistent with observations that major depression is the predominant type of bipolar moodepisode during pregnancy [ 46 ], and in the general population of bipolar patients [ 47,48 ]. Comorbid anxietydisorders and substance use disorders are common among patients with postpartum bipolar depression [ 49,50 ],which is also seen in the general population of bipolar patients [ 51,52 ]. The general clinical features of bipolar disorder are discussed separately. (See "Bipolar disorder in adults: Clinical features" .)

Other symptoms commonly observed in postpartum bipolar mood episodes include mood lability and preoccupationwith the newborn [ 6,53 ].

Onset of postpartum bipolar mood episodes appears to be greatest within the first few weeks after delivery,based upon retrospective studies [ 5]:

A study of 630,373 primiparous pregnant women found that hospitalization for a postpartum bipolar episodewas 23 times more likely within the first 30 days of delivery, compared with 11 to 12 months postpartum [ 9].

A study of 10,218 primiparous bipolar patients found that recurrent mood episodes occurred 37 t imes moreoften 10 to 19 days after delivery, compared with 6 to 11 months postpartum [ 16 ].

One study of primiparous bipolar I mothers (N = 980) found that the median time to a mood episode wasone week and for bipolar II mothers (N = 232), two to three weeks [ 54 ]. A second study of 127 bipolar patients with postpartum mood episodes found that symptoms began on the day of delivery in 40 percentand within three days of parturition in 73 percent [ 26 ].

Postpartum bipolar mood episodes often progress rapidly [ 53 ], and the mean duration of episodes varies fromapproximately one to three months [ 19,55 ].

Psychotic features Onset of postpartum psychosis in bipolar patients generally occurs within the first two tothree weeks of parturition [ 13,24,53,56 ]. The clinical features of postpartum bipolar psychosis can include[13,26,36,57 ]:

DelusionsHallucinationsDisorganized or bizarre behavior Disorganized thinkingCognitive impairment or confusionImpaired judgement

AgitationSleep disturbanceMood labilityImpulsivity

Postpartum bipolar patients with psychotic mood episodes may be at increased risk for suicide and infanticide [ 27 ].

Additional information about postpartum psychosis and the clinical features of psychosis are discussed separately.(See "Postpartum psychosis: Epidemiology, clinical manifestations, and assessment" and "Overview of psychosis",section on 'Psychosis' .)


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episodes of mania and hypomania, and has good psychometric properties ( table 4 ) [66,67 ]. A study of postpartum patients (57 with bipolar disorder and 68 with unipolar major depression, established bystructured interview) found that the sensitivity was 75 percent and specificity 87 percent [ 65 ]; comparableresults have been found in psychiatric [ 68 ] and family medicine outpatients [ 69 ]. Eliminating thesupplementary questions in sections 2 and 3 may improve the utility of the instrument for postpartumpatients [ 65,70 ]. The Mood Disorder Questionnaire does not generate a diagnosis of mania or hypomania;thus, patients who screen positive require a clinical interview to make the diagnosis.

Patient Health Questionnaire - 9 Item (PHQ-9). This 9-item instrument screens for episodes of major depression, provides a diagnosis, and has good psychometric properties ( table 5 ) [71 ]. In addition, thePHQ-9 has been used as a screening tool for postpartum depression [ 72 ]. The PHQ-9 is discussedseparately. (See "Using scales to monitor symptoms and treat depression (measurement based care)",section on 'Patient Health Questionnaire - Nine Item' .)

Several reasonable alternatives to the Mood Disorder Questionnaire are available [ 66 ]. As an example, postpartumpatients presenting with major depression can be screened for bipolar I disorder and bipolar II disorder by askingabout a family history of bipolar disorder [ 29,73 ], or with the Screening Assessment of Depression-Polarity, whichis a three item, clinician administered instrument [ 74 ]. Patients who screen positive require a follow-up interview toestablish the diagnosis of bipolar disorder.

A reasonable alternative to the PHQ-9 is the Edinburgh Postnatal Depression Scale, which is a 10-item, self reportinstrument that screens for postnatal depression and is widely used ( figure 1A-B ). The original validation studyfound that the psychometric properties were good: sensitivity was 86 percent, specificity 78 percent, and positivepredictive value 73 percent [ 75 ]. However, a systematic review of 37 studies found that sensitivity ranged from 34to 100 percent and specificity from 44 to 100 percent [ 76 ].

It is not known whether screening instruments improve outcome for postpartum bipolar patients. However, arandomized trial compared the Edinburgh Postnatal Depression Scale with clinical assessment in screening for postnatal unipolar major depression, and found that maternal mental health outcomes were significantly better among those screened with the Edinburgh Postnatal Depression Scale [ 77 ].

DIAGNOSIS There are three subtypes of bipolar disorder that can be diagnosed, depending upon the moodsymptoms and episodes that have occurred [ 6]:

Bipolar IBipolar IIBipolar disorder not otherwise specified

The diagnostic criteria for each subtype of bipolar disorder are identical for postpartum and nonpostpartumpatients. Diagnosis of bipolar disorder is discussed separately. (See "Bipolar disorder in adults: Assessment anddiagnosis", section on 'Diagnosis' .)

Differential diagnosis The differential diagnosis of bipolar disorder includes schizophrenia, schizoaffectivedisorder, unipolar major depression, and substance use disorder, and is discussed separately. (See "Bipolar disorder in adults: Assessment and diagnosis", section on 'Differential diagnosis' .)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics andBeyond the Basics. The Basics patient education pieces are written in plain language, at the 5 to 6 gradereading level, and they answer the four or five key questions a patient might have about a given condition. Thesearticles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyondthe Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are writtenat the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortablewith some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail thesetopics to your patients. (You can also locate patient education articles on a variety of subjects by searching onpatient info and the keyword(s) of interest.)

th th

th th


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Basics topics (See "Patient information: Bipolar disorder (The Basics)" and "Patient information: Reducingthe costs of medicines (The Basics)" .)

Beyond the Basics topics (See "Patient information: Bipolar disorder (manic depression) (Beyond theBasics)" and "Patient information: Reducing the costs of medicines (Beyond the Basics)" .)

These educational materials can be used as part of psychoeducational psychotherapy. (See "Bipolar disorder inadults: Maintenance treatment", section on 'Psychoeducation' .)

The National Institute of Mental Health also has educational material explaining the symptoms, course of illness,and treatment of bipolar disorder in a booklet entitled "Bipolar Disorder," which is available online at the websitehttp://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml or through a toll-free number,866-615-6464. The web site also provides references, summaries of study results in language intended for the laypublic, and information about clinical trials currently recruiting patients.

More comprehensive information is provided in many books written for patients and family members, including TheBipolar Disorder Survival Guide: What You and Your Family Need to Know, written by David J. Miklowitz, PhD(published by The Guilford Press, 2002); An Unquiet Mind: A Memoir of Moods and Madness, written by KayJamison, PhD (published by Random House, 1995); and Treatment of Bipolar Illness: A Casebook for Clinicians

and Patients, by RM Post, MD, and GS Leverich, LCSW (published by Norton Press, 2008).

The Depression and Bipolar Support Alliance ( http://www.dbsalliance.org or 800-826-3632) is a nationalorganization that educates members about bipolar disorder and how to cope with it. Other functions includeincreasing public awareness of the illness and advocating for more research and services. The organization isadministered and maintained by patients and family members, and has local chapters.

The National Alliance on Mental Illness ( http://www.nami.org or 800-950-6264) is a similarly structured organizationdevoted to education, support, and advocacy for patients with any mental illness. Bipolar disorder is one of their priorities.

SUMMARY AND RECOMMENDATIONS

Onset of postpartum bipolar mood episodes occurs within a limited time period following birth of a live child;definitions of the puerperium range from the first 1 to 12 months following a live birth. (See 'Definitions'above.)

The risk of mood episodes in female bipolar patients may be greater during the puerperium than at other times, with episodes occurring after 25 to 50 percent of deliveries. (See 'Epidemiology' above.)

The etiology of postpartum bipolar mood episodes is not known. Possible causes include decreases inserum estrogen and progesterone concentrations, disrupted sleep, increased stress, social issues, andgenetic effects. (See 'Pathogenesis' above.)

Bipolar disorder is characterized by episodes of major depression ( table 3 ), mania ( table 1 ), and hypomania(table 2 ), as well as mixed episodes (major depression concurrent with mania or hypomania). The mostcommon type of postpartum episode is major depression, and psychotic features (eg, delusions andhallucinations) are frequently present. Most postpartum episodes occur during the f irst several (eg, four)weeks after delivery, and the mean duration of episodes varies from approximately one to three months.(See 'Clinical manifestation' above.)

The course of illness in bipolar patients with a lifetime history of postpartum mood episodes and patientswithout this history does not appear to differ. Postpartum bipolar mood episodes are often followed bysubsequent postpartum and nonpostpartum episodes. (See 'Course of illness' above.)

The assessment of postpartum patients with a possible diagnosis of bipolar disorder includes a psychiatricand general medical history, mental status and physical examination, and focused laboratory tests, withemphasis upon mood and psychotic symptoms, including thoughts of suicide and homicide. Postpartumhypomania and a prior history of hypomania are both easy to miss. (See 'Assessment' above.)


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Self-report instruments that screen for mania, hypomania, and major depression, and are easy to use,include the Mood disorder Questionnaire ( table 4 ) and Patient Health Questionnaire - 9 Item ( table 5 ). (See'Screening' above.)

There are three subtypes of bipolar disorder that can be diagnosed in postpartum patients: bipolar Idisorder, bipolar II disorder, and bipolar disorder not otherwise specified. (See 'Diagnosis' above and"Bipolar disorder in adults: Assessment and diagnosis", section on 'Diagnosis' .)

The differential diagnosis of bipolar disorder includes schizophrenia, schizoaffective disorder, unipolar major depression, and substance use disorder. (See "Bipolar disorder in adults: Assessment and diagnosis",section on 'Differential diagnosis' .)

Use of UpToDate is subject to the Subscription and License Agreement .

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GRAPHICS

DSM-IV-TR diagnostic criteria for mania

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lastingat least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have

persisted (four if the mood is only irritable) and have been present to a significant degree:1) Inflated self-esteem or grandiosity

2) Decreased need for sleep (eg, feels rested after only 3 hours of sleep)

3) More talkative than usual or pressure to keep talking

4) Flight of ideas or subjective experience that thoughts are racing

5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli)

6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotoragitation

7) Excessive involvement in pleasurable activities that have a high potential for painful consequences(eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a mixed episode.

D. The mood disturbance 1) is sufficiently severe to cause marked impairment in occupationalfunctioning, usual social activities, or relationships with others, 2) necessitates hospitalization toprevent harm to self or others, or 3) has psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision,Fourth Edition (Copyright 2000). American Psychiatric Association.


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DSM-IV-TR diagnostic criteria for hypomania

A. A distinct period of persistently elevated, expansive, or irr itable mood, lasting at least 4 days,that is clearly different from the usual nondepressed mood.

B. During the period of mood disturbance, three (or more) of the following symptoms havepersisted (four if the mood is only irritable) and have been present to a significant degree:

1) Inflated self-esteem or grandiosity

2) Decreased need for sleep (eg, feels rested after only 3 hours of sleep)

3) More talkative than usual or pressure to keep talking

4) Flight of ideas or subjective experience that thoughts are racing

5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli)

6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotoragitation

7) Excessive involvement in pleasurable activities that have a high potential for painful consequences(eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of

the person when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode 1) is not severe enough to cause marked impairment in social or occupationalfunctioning, 2) does not necessitate hospitalization, and 3) does not have psychotic features.

F. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).

Note : Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (eg,medication, ECT, light therapy) should not count toward a diagnosis of bipolar II disorder.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision,Fourth Edition (Copyright 2000). American Psychiatric Association.


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DSM-IV-TR diagnostic criteria for major depression

A. Five (or more) of the following symptoms have been present during the same 2-weekperiod, and represent a change from previous functioning. At least one of the symptoms is eitherdepressed mood or loss of interest or pleasure.

(Note: Do not include symptoms that are clearly due to a general medical condition, ormood-incongruent delusions or hallucinations.)

Depressed mood most of the day, nearly every day (or alternatively can be irritable mood in childrenand adolescents)

Markedly diminished interest or pleasure in all, or almost all, activities, nearly every day

Significant weight loss while not dieting, weight gain, or decrease or increase in appetite

Insomnia or hypersomnia nearly every day

Psychomotor agitat ion or retardation nearly every day

Fatigue or loss of energy nearly every day

Feelings of worthlessness or excessive or inappropriate guilt nearly every day

Diminished ability to think or concentrate, or indecisiveness, nearly every day

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specificplan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or otherimportant areas of functioning.

D. The symptoms are not due to the direct physiological effects of substance or a general medicalcondition.

E. The symptoms are not better accounted for by Bereavement, ie, after the loss of a loved one,the symptoms persist for longer than two months or are characterized by marked functional

impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, orpsychomotor retardation.

Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4thed, Text Revision. American Psychiatric Association, Washington, DC 2000.


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Mood disorder questionnaire

1. Has there ever been a period of time when you were notyour usual self and...

Yes No

...you felt so good or so hyper that other people thought you werenot your normal self or you were so hyper that you got into trouble?

...you were so irritable that you shouted at people or started fights

or arguments?

...you felt much more self-confident than usual?

...you got much less sleep than usual and found you didn't reallymiss it?

...you were much more talkative or spoke faster than usual?

...thoughts raced through your head or you couldn't slow your minddown?

...you were so easily distracted by things around you that you hadtrouble concentrating or staying on track?

...you had much more energy than usual?

...you were much more active or did many more things than usual?

...you were much more social or outgoing than usual, for example,you telephoned friends in the middle of the night?

...you were much more interested in sex than usual?

...you did things that were unusual for you or that other peoplemight have thought were excessive, foolish, or risky?

...spending money got you or your family into trouble?

2. If you checked YES to more than one of the above, haveseveral of these ever happened during the same period of time? Please circle one response only.

Yes No

3. How much of a problem did any of these cause you - like being unable towork; having family, money, or legaltroubles; getting into arguments orfights? Please circle one response only.

Noproblem

Minorproblem

Moderateproblem

Seriousproblem

Patients screen positively for bipolar disorder if they answer "yes" to seven or more items insection 1, "yes" in section 2, and "moderate problem" or "serious problem" in section 3.The mood disorder questionnaire should not be used to diagnose bipolar disorder. Patientswho screen positive should be interviewed to establish the diagnosis; including familymembers is often helpful.Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry 2000; 157:1873. Reprinted with permission from the American Journal of Psychiatry (Copyright 2000). American Psychiatric

Association.


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Appendix A: Edinburgh postnatal depression scale(EPDS)

Reproduced with permission from: JL Cox, JM Holden, R Sagovsky. Department of Psychiatry, University of Edinburgh.


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Appendix A: Edinburgh postnatal depression scale(EPDS) (con't)

A score of 12 or more identifies most women with postpartumdepression. Women who report depressive symptoms withoutsuicidal ideation or major functional impairment (or score between 5and 9 on the EPDS) should be reevaluated within one month.Reproduced with permission from: JL Cox, JM Holden, R Sagovsky. Department of Psychiatry, University of Edinburgh.


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