Bipolar disorder may present as depression, but it also consists of manic periods of elevated, expansive, or irritable mood that last several days to weeks. Many symptoms appear to be the opposite of depression, such as increased energy and elevated self-esteem.7,8
It is important to consider bipolar disorder in the differential diagnosis. If a woman who has unrecognized bipolar disorder is given an antidepressant, a manic state could be precipitated. Women who have bipolar disorder require different drugs than women who have depression only, and they should be evaluated by a psychiatrist, at least initially.
Start treatment as soon as possible
Once you confirm that the patient has postpartum depression—and not another psychiatric disorder—prescribing an antidepressant may be the next step. Keep in mind that these drugs take several weeks before their benefits are felt. Therefore, it is best to start an antidepressant before depression becomes severe. The mother may also benefit from psychotherapy.
The selective serotonin reuptake inhibitor sertraline (Zoloft) is a reasonable first choice in pregnancy and lactation when the depression is of new onset.9,10 Start it gradually (e.g., 25 mg for sertraline, which can cause nausea if it is initiated too rapidly) and titrate it over time, if necessary. When there is comorbid anxiety, it sometimes is helpful to prescribe low dosages of lorazepam (Ativan, Temesta) on an as-needed basis, while the patient is waiting for the antidepressant to “kick in.” Also consider follow-up—do you plan to follow her frequently or refer her to psychiatry?
Adjunctive or alternative options include psychotherapy, group therapy, and music therapy. Referral to a psychiatrist is warranted if the patient does not respond to the initial antidepressant agent.
Also be aware that untreated depression can become so severe that a woman can begin to experience psychosis, warranting rapid referral. Also refer any woman who reports a complex history of previous depression—unless the previous episode was easily controlled with a medicine safe for use during pregnancy and lactation.
If the patient is not lactating, a greater range of agents may be considered. (A full discussion of the risks and benefits of antidepressant use in pregnancy is outside the scope of this article. The interested reader is referred to an article on the subject by Wisner and colleagues.11)
CASE 1 RESOLVED
A comprehensive discussion with the mother reveals that she is suffering from postpartum depression. No history of bipolar or psychotic symptoms is discovered. After discussing treatment options, you prescribe sertraline. Over the next 2 months, the patient’s symptoms improve, and she bonds with her infant and successfully returns to work. She is also referred to a psychologist to work through some underlying issues.
Leaving against medical advice
CASE 2: Patient threatens to leave the hospital
At midnight, you are paged to attend to a 32-year-old G1P0 at 27 weeks’ gestation who is threatening to leave against medical advice. She was admitted earlier in the day with uncontrolled gestational diabetes and is refusing her insulin.
How do you respond?
Use the relationship that you have established with this patient to the best of your ability. Make sure that you have explained fully, and in language she can easily comprehend, the reasons she needs to stay for treatment.
Don’t overlook the obvious, either: Why does she want to leave? Sometimes the reason makes sense (e.g., one mother wanted to leave to protect her daughter from an abusive husband). Other reasons may be related to psychosis, addiction, lack of sleep in the hospital, or a desire to smoke, drink, or use drugs. Can you convince her to postpone her decision until morning, when her physician will be available?
It is important to document in the medical record your explanations and her reasoning. Can she coherently verbalize an understanding of the consequences of her decision to leave, including the risks and implications to herself and the fetus?12 Can she describe alternatives and the reasoning against them?
If she is able to do these things, and you find her thought processing and reasoning to be lucid, then she may have the capacity to leave against medical advice. Keep in mind that rational persons do have the right, constitutionally, to refuse treatment, even if doing so will lead to morbidity. (A Jehovah’s Witness who refuses treatment is the typical example.12) Contact the hospital’s attorney—tonight—and document that you did so. The attorney may recommend that the patient sign a letter stating that she recognizes the maternal and fetal risks of leaving.