Postpartum Depression Screening

Postpartum depression has been called "the most common problem associated with childbirth," affecting about 13% of new mothers, or approximately 500,000 women each year (1). Postpartum depression (PPD) can have lasting effects on mothers and babies; untreated (or insufficiently treated), it can lead to bonding difficulties and developmental delays in infants (2). Women who experience PPD report the typical symptoms of situational or chronic depression: sadness; loss of energy; changes in eating habits (significantly decreased or increased apetite); emotional numbness; insomnia; loss of interest in sex; irritability and anger (sometimes intense), as well as mood swings, poor bonding, and strong feelings of shame and guilt associated with cultural disapproval of perceived weakness or selfishness of mothers who feel anything less than total bliss towards their new babies (4).

At least half of these mothers, and potentially many more, are never diagnosed, and may suffer needlessly-- a true tragedy of modern medicine, considering that screening for the disorder is simple, fast, reliable, and inexpensive. There are several tools available to screen new mothers for PPD; the most common is the tried-and-true Edinburgh Postnatal Depresson Scale (5), which was developed in the UK and has been used for over 20 years to reliably predict patients' risk of developing PPD (6,7). The format is simple: a 10-item self-administered questionnaire, which should be answered by the mother herself, that can be completed in about five minutes and reviewed immediately with care providers. The tool is available at no cost to the administering institution, and can be duplicated with attribution; it is easy to score and results are instantaneous. Each item is scored with 0, 1, 2, or 3 points, and the resulting score is compared to a standardized scale-- the higher the score (30 is the maximum), the more likely the woman is to develop PPD. A score of 12 or higher is considered to be predictive of PPD, while a score of 21-30 is considered high risk and may necessitate immediate consult with the woman's physician (8).

The EPDS has been validated as effective by many quantitative studies, although sound clinical judgment should always be used in interpreting results (10). Each individual found to be at risk should be evaluated by a medical professional not only shortly after birth, but at the initial postpartum checkup (4-6 weeks), and, ideally, at 3 and 6 months postpartum (11). Some researchers have suggested that screening should be done not only in obstretric offices, but in pediatric clinics as well, to facilitate the identification of as many cases as possible (12). Further, since most mothers who experience PPD also experienced at least one depressive episode prenatally, it has been recommended by some that obstetricians should screen their pregnancy patients at least once per trimester during routine prenatal care (13). While ACOG (the American College of Obstetricans and Gynecologists) cites inadequate evidence to recommend a standard of care, they do recognize the need for screenings, as well as treatment, follow up, and referral as required (14).






References Cited



1.  http://www.medicinenet.com/postpartum_depression/article.htm,  retrieved 10/20/2012

2. Is your new mom depressed? (Did you ask?) Schaar GL - Journal for Nurse Practitioners -  November/December 2011; 7(10); 879-880

3.  http://www.mayoclinic.com/health/postpartum-depression/DS00546/DSECTION=symptoms,  retrieved 10/20/2012

4.  http://www.postpartumprogress.com/6-surprising-symptoms-of-postpartum-depression-and-anxiety,  retrieved 10/20/2012

5.  http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf,  retrieved 10/20/2012

6. Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item

Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.

7. Applying new techniques to an old ally: A qualitative validation study of the Edinburgh Postnatal Depression Scale

Godderis R - Women Birth - March, 2009; 22(1); 17-23

8. Schaar 2011

9. Godderis 2009

10. Mothers With Positive or Negative Depression Screens Evaluate a Maternal Resource Guide

Pascoe JM - Journal of Pediatric Health Care - November/December 2010; 24(6); 378-384

11.Screening for postpartum depression. Cole C - Journal for Nurse Practitioners - 01 January 2009; 5(6): 460-461

12. Pascoe 2010

13. Screening for perinatal depression with limited psychiatric resources. Jevitt, C., Zapata, L., Harrington, M., and Berry, E. Journal of the American Psychiatric Nurses Association, Vol. 11, No. 6

14. Screening for Depression During and After Pregnancy. Committee on Obstretic Practice, American College of Obstetricians and Gynecologists, February 2010. Retrieved from  http://www.acog.org/~/media/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/co453.pdf?dmc=1&ts=20121020T1538438353,  10/20/2012

If it's Thursday, it must be...

Work.

Well, that's where I am now, as I am most Thursdays. Today hasn't been a bad Thursday, as Thursdays go; still, I'm with Arthur Dent: "This must be Thursday. I never could get the hang of Thursdays."

Thursday tends to be a busy day on the average L&D unit. Lots of scheduled cesareans and inductions: the physicians reason that the vaginal deliveries will go home Friday, or possibly Saturday; they reason that, if the former, they'll see them tomorrow, and if not, well, they can leave a prescription on the chart for pain medication and let whomever is covering for the weekend worry about it. The cesareans will stay the weekend and leave Monday-- maybe Sunday, but again, that's for the on call colleague to decide.

Today the inductions have gone slow-- only one vag birth so far to be admitted to us in mother/baby. Another apparently failed the Friedman Curve an hour ago and was sectioned, so the next shift will have a fresh surgery to contend with. Other days they fly, and babies seem to pop out right, left, and sideways! It's my Friday-- ie, the last day I'm scheduled to work this week-- and I'm grateful it's been a relatively quiet one, for once.

Since it's been a calmer sort of day, I was able to put the finishing touches on an inservice I've got to present on postpartum depression. Here's a quote from the informational letter we'll be giving patients:

Up to 80% of new mothers feel stressed or cry easily after having a baby. This is commonly referred to as "baby blues." These feelings are normal and usually resolve in a few weeks. Postpartum depression is a mood disorder that affects a high percentage of women-- as many as 1 in every 8-- anytime in the first year after their child is born, or after a miscarriage or stillbirth. In the United States, about 400,000 women-- roughly 1 in 650-- may develop postpartum depression each year. A significant number of these will go undiagnosed, and may suffer needlessly...

Postpartum depression is, in my humble opinion, no joke (unlike Tom Cruise, who is!). I essentially lost the first year of my older son's life due to undiagnosed major depression and post-traumatic stress related to a traumatic delivery. The public is woefully undereducated on this topic; even in this day and age, new mothers are handed the unfeeling line, "What's to be depressed about? You just had a beautiful baby!" and worse, ""Get over it!" It's not that simple, as any mother who's tried to cope with the demands of a new infant and the realities of a dark depression can attest. Sure, good nutrition and excellent support will help alleviate the symptoms, but I hate to tell you, they're not a panacea. Sometimes-- much as it may gall me to admit it-- medication is indicated.

I've never had much luck with talk therapy-- I hate going through the ordeal of finding a therapist, meeting him or her, weeping my way through an intake appointment, reciting my woes and stresses and (loooooong) history of depression, and basically reiterating the whole boring saga of how I arrived at this particular point. I feel guilty about inflicting myself on counselors-- no one wants to listen to the baggage I have to offload, even if they are getting paid for it! Medication is safely private-- you can't induce ennui in a capsule of fluoxetine. Of course, your more conscientious physicians will insist that you return periodically to re-up your prescription, although in my experience it's largely a formality. Ideally, one should work with one's care provider vis-a-vis follow-ups, the monitoring of lab values, etc; if your doctor doesn't offer, it's recommended-- if not, indeed, imperative-- that you insist on regular assessments yourself. No matter what they tell you, all medications have side effects; it's best to be aware of them and proactive about addressing them as they arise.

In my experience, whatever the unpleasant symptoms associated with the antidepressants I've personally tried (Prozac, Zoloft, Wellbutrin), they were peanuts compared to the black pit of despair I inhabited after my son's arrival into the world in July 2002. I went to bed every night with the distinct hope that I wouldn't wake up. I cringe to admit that now-- I adored my sweet baby, but I firmly believed I was no good to him whatsoever and he would be immeasurably better off without such a useless mother.

I wouldn't wish that hell on anyone. I stayed there entirely too long, unable to escape the sucking despair. Finally I managed to drag myself to a family practice physician, who prescribed Zoloft, then Prozac. After long weeks, it worked-- I realized I no longer hoped for death. I flirted with guilt for awhile-- why couldn't I be strong enough to get by without the meds?-- but I let that go. The medication allowed me to function again, as a mother and as a human being. I could get up in the morning. I could (and did) breastfeed my child on demand-- and he didn't grow an extra head, or suffer any other setbacks that I've noticed in the intervening years. For me, it was worth it. Do I wish I hadn't had that mess to deal with? Certainly. Am I thrilled that, for me, it appears that antidepressants are an ongoing part of life? Not so much. But my kids have a (mostly) functional mother, and for that reason, I'm okay with it.