Alex T,* a 23-year-old first-time mom, presented to the family medicine office for her baby’s 2-week appointment. When asked how she was doing, she began to cry. She said, “I feel crazy” and indicated that she was feeling down and overwhelmed, and was struggling to bond with the baby. She filled out an Edinburgh Postnatal Depression Scale, a standard postpartum depression (PPD) screen; her score, 15 out of 30, was suggestive of depression. Ms. T had been coming to the practice for the past 3 years and had no significant physical or mental health history. She and the baby did not live with the baby’s father, and his degree of presence in their lives varied.
● How would you proceed with this patient?
* The patient’s name has been changed to protect her identity.
PPD, traditionally defined as depression in the postpartum period for as long as a year after childbirth, is a common, underdiagnosed outcome of both normal and complicated pregnancies.1 Peripartum depression, which includes PPD and depression during pregnancy, occurs in approximately 10% of pregnancies.2,3When depression first appears in the postpartum period, most women develop symptoms in the first month after delivery (54% of cases) or in the next 2 to 4 months (40%).4
The most significant risk factor for PPD is previous depression, peripartum or otherwise.1,4-6 Other common risk factors include major life events or stressors during or after pregnancy, domestic violence, poor social support, and preterm birth or an infant admission to the neonatal intensive care unit.1,7 Women with a self-perceived negative birth experience are also likely to experience PPD.8 PPD can be associated with significant morbidity and mortality, with suicide a more common cause of maternal mortality than either hemorrhage or hypertensive disorders of pregnancy.9
Women with postpartum anemia and low ferritin stores are more prone to depression than are those with normal levels.
Early diagnosis and intervention are crucial to improving patient outcomes. Women with PPD initiate breastfeeding at lower rates and continue for shorter durations.10 PPD also affects maternal–infant bonding; may adversely affect an infant’s social, cognitive, and language development; and may lead to attachment disorders of infancy.11,12 In severe cases, it can lead to failure to thrive or infanticide.11
When to screen. The US Preventive Services Task Force (USPSTF) recommends clinicians screen for depression in pregnant and postpartum women (Grade Ba) and for women at increased risk, provide or refer to counseling interventions (Grade Ba).13,14 The American College of Obstetricians and Gynecologists (ACOG) recommends screening at least once in the postpartum period.15 Repeat screening at follow-up in the later postpartum period increases the likelihood of diagnosis.16 Screening for PPD as part of well-child care improves maternal outcomes, and the American Academy of Pediatrics recommends screening at the 1-, 2-, 4-, and 6-month visits.11,17 These screens are separately billable. Family physicians are uniquely suited to screening at both well-child and postpartum visits, as many women share a medical home with their child, and those who do not are equally willing to receive medical advice from their child’s physician.18
Continue to: Is it "the blues" or something else? Diagnosing PPD
