The Recognition & The Recognition & Treatment of Treatment of Postpartum Postpartum DepressionDepressionJohna M BottJohna M Bott

Eileen Van DykeEileen Van Dyke

3/23/063/23/06

PPDPPD

Characterized by despair, sadness, Characterized by despair, sadness, anxiety, fears, compulsive thoughts, anxiety, fears, compulsive thoughts, feelings of inadequacy, loss of feelings of inadequacy, loss of libido, fatigue, & dependencylibido, fatigue, & dependency

Affects upwards of 20% of women Affects upwards of 20% of women after childbirthafter childbirth

Major health problem that Major health problem that threatens the family unit as a wholethreatens the family unit as a whole

Postpartum psychosisPostpartum psychosis

Emergency that requires Emergency that requires immediate hospitalizationimmediate hospitalization

Presents with mania, psychotic Presents with mania, psychotic thoughts, severe depressionthoughts, severe depression

Rare occurring in 1-2 deliveries Rare occurring in 1-2 deliveries out of a thousandout of a thousand

Why do we care?Why do we care?

Affects entire family unit, not just the motherAffects entire family unit, not just the mother One mother described PPD as being buried One mother described PPD as being buried

alive with no chance of clawing to the surfacealive with no chance of clawing to the surface While mom is debilitated, child’s cognitive While mom is debilitated, child’s cognitive

and social development suffers then & and social development suffers then & potentially later on in life with the potentially later on in life with the development of conduct & attention disordersdevelopment of conduct & attention disorders

Fathers also affected by stress put on Fathers also affected by stress put on marriagemarriage

PPD PPD screening is screening is

not being not being donedone

ScreeningScreening

Approximately 50% of PPD cases go Approximately 50% of PPD cases go undiagnosedundiagnosed

Although family physicians believe PPD is Although family physicians believe PPD is serious, identifiable, and treatable, serious, identifiable, and treatable, screening is still not standard clinical screening is still not standard clinical practice in the USpractice in the US

Clinical signs are often not apparent Clinical signs are often not apparent unless screened forunless screened for

Screening tools are out there & some are Screening tools are out there & some are even specific for PPDeven specific for PPD

ExcusesExcuses

OB screens for thatOB screens for that Pediatricians screen for that at Pediatricians screen for that at

well baby visitswell baby visits There are too many tools out There are too many tools out

there, I don’t know which one to there, I don’t know which one to useuse

The tools are too complexThe tools are too complex Is that my job?Is that my job?

Risk FactorsRisk Factors

Prenatal depressionPrenatal depressionTotally independent of timeTotally independent of timeAny depression during Any depression during

pregnancy was discovered to pregnancy was discovered to be a significant predictorbe a significant predictor

Risk FactorsRisk Factors

Child care stressChild care stress Childbirth itself is a traumatic Childbirth itself is a traumatic

stressful event that makes the mother stressful event that makes the mother more vulnerable to other stressorsmore vulnerable to other stressors

Any stressful event involving the care Any stressful event involving the care of the newborn, including the of the newborn, including the temperament of the baby which may temperament of the baby which may be fussy, irritable, and difficult to be fussy, irritable, and difficult to consoleconsole

Unhealthy infantsUnhealthy infants

Risk FactorsRisk Factors

Support or lack there ofSupport or lack there ofSocial, emotional, and Social, emotional, and

instrumental support is very instrumental support is very important for new mothers and important for new mothers and either perceiving a lack of it or either perceiving a lack of it or actually having a lack of it can actually having a lack of it can be very detrimentalbe very detrimental

Risk FactorsRisk Factors

Life stressLife stressThe number of both positive The number of both positive

and negative stressful life and negative stressful life events that occur during events that occur during pregnancy and the postpartum pregnancy and the postpartum periodperiod

Risk FactorsRisk Factors

Prenatal anxietyPrenatal anxietyMarital dissatisfactionMarital dissatisfactionHistory of previous History of previous

depressiondepressionAffective illness or previous Affective illness or previous

PPD episodePPD episode

Medical Problems with Medical Problems with Related SxRelated Sx

Transient hypothyroidismTransient hypothyroidism AnemiaAnemia DiabetesDiabetes Other endocrine disordersOther endocrine disorders Abuse situationsAbuse situations InfectionInfection

Treatment OptionsTreatment Options

Individual psychotherapyIndividual psychotherapy Personalized carePersonalized care Scheduling flexibilityScheduling flexibility

Group therapyGroup therapy Not for everyoneNot for everyone Compliance issue with scheduling Compliance issue with scheduling

conflictsconflicts Need adequate # to participateNeed adequate # to participate

Treatment OptionsTreatment Options

Pharmacologic treatmentPharmacologic treatment Selective serotonin reuptake inhibitors (SSRIs)Selective serotonin reuptake inhibitors (SSRIs) All antidepressants are secreted in breast milkAll antidepressants are secreted in breast milk Continued at least six months to ensure Continued at least six months to ensure

complete remissioncomplete remission Complementary or alternative treatmentsComplementary or alternative treatments

Bright-light therapy, exercise, massage Bright-light therapy, exercise, massage therapy, & chronobiological therapies, such as therapy, & chronobiological therapies, such as wake therapywake therapy

Treatment OptionsTreatment Options

Controversial therapiesControversial therapies Progesterone or estrogen Progesterone or estrogen

injectionsinjections HospitalizationHospitalization

Risk of suicide or infanticideRisk of suicide or infanticide AntipsychoticsAntipsychotics Electroconvulsive therapyElectroconvulsive therapy

Available Screening Available Screening ToolsTools

The Beck Depression InventoryThe Beck Depression Inventory The Bromley Postnatal Depression ScaleThe Bromley Postnatal Depression Scale The Center for Epidemiological Studies The Center for Epidemiological Studies

Depression ScaleDepression Scale The General Health QuestionnaireThe General Health Questionnaire The Inventory of Depressive The Inventory of Depressive

SymptomatologySymptomatology The Zung Self-Rating Depression ScaleThe Zung Self-Rating Depression Scale The Edinburgh Postnatal Depression ScaleThe Edinburgh Postnatal Depression Scale The Postpartum Depression Screening ScaleThe Postpartum Depression Screening Scale

The Edinburgh Postnatal The Edinburgh Postnatal Depression ScaleDepression Scale

One of the best known screening One of the best known screening scales for PPDscales for PPD

Measures emotional and cognitive Measures emotional and cognitive symptoms of PPDsymptoms of PPD

Ten items scored from 0 to 3Ten items scored from 0 to 3 Only somatic sx taken into account is Only somatic sx taken into account is

sleeping difficultiessleeping difficulties Available in multiple languagesAvailable in multiple languages

The Postpartum Depression The Postpartum Depression Screening ScaleScreening Scale

Measures 7 dimensions of PPD Measures 7 dimensions of PPD including sleeping/eating including sleeping/eating disturbances, anxiety/insecurity, disturbances, anxiety/insecurity, emotional liability, cognitive emotional liability, cognitive impairment, loss of self, guilt/shame, impairment, loss of self, guilt/shame, & contemplating harming oneself& contemplating harming oneself

35 items35 items Excellent sensitivity & specificityExcellent sensitivity & specificity

ConclusionConclusion

The general consensus is that The general consensus is that both the EPDS & the PDSS are both the EPDS & the PDSS are good screening scales for PPDgood screening scales for PPD

Practitioners may form personal Practitioners may form personal preferences due to length or preferences due to length or detail of questionsdetail of questions

Most important thing is that a Most important thing is that a screening method is usedscreening method is used

SummarySummary

PPD is real & very seriousPPD is real & very serious Talking about PPD openly might make it Talking about PPD openly might make it

less scary, educate the patient & their less scary, educate the patient & their familyfamily

Screening at every visit is the key to the Screening at every visit is the key to the difficult recognition that is due to drastic difficult recognition that is due to drastic differences in symptoms from patient to differences in symptoms from patient to patientpatient

Prompt treatment with effective follow-Prompt treatment with effective follow-upup

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