The Journal for Nurse Practitioners
Volume 2, Issue 4 , Pages 247-253, April 2006

Postpartum Depression: Detection and Treatment in the Primary Care Setting

  • Christina Munoz, RN, BSN

      Affiliations

    • All authors work at Rush University Medical Center in Chicago, IL.
    • Christina Munoz, RN, BSN, is a clinical nurse II and FNP candidate.
    • ,
  • Janyce Agruss, DNSc, APN/CNP

      Affiliations

    • All authors work at Rush University Medical Center in Chicago, IL.
    • Janyce Agruss, DNSc, APN/CNP, is an assistant professor and coordinator for the family nurse practitioner program.
    • ,
  • Amy Haeger, MSN, FNP

      Affiliations

    • All authors work at Rush University Medical Center in Chicago, IL.
    • Amy Haeger, MSN, FNP, is a women's health consultant.
    • ,
  • Lynn Sivertsen, MSN, RN, APRN

      Affiliations

    • All authors work at Rush University Medical Center in Chicago, IL.
    • Lynn Sivertsen, MSN, RN, APRN, is an assistant professor.

Article Outline

ABSTRACT 

Postpartum depression (PPD) is an illness that is often overlooked. Its consequences suggest that nurse practitioners should be more proactive in looking for this problem. This article provides the advanced practice nurse with the necessary tools to assess risk, screen, recognize symptoms, and diagnose PPD based on current literature. Treatments are highlighted, and resources for the practitioner are provided. A case study is presented to illustrate current treatment guidelines in a primary care setting.

Keywords:  baby blues , depression , postpartum , postpartum blues , postpartum depression

 

Postpartum depression (PPD) is a significant mental health problem that affects women and their families worldwide. PPD is a medical diagnosis with specific diagnostic criteria. This article is intended to help the advanced practice nurse (APN) who works with postpartum patients identify women at risk, understand how to correctly diagnose PPD, and obtain appropriate and lifesaving treatment for the women in need.

Back to Article Outline

PREVALENCE 

The prevalence of PPD varies depending on the study method used and timing of evaluation. A meta-analysis of community studies found the prevalence of PPD to be 13%.1 Globally, published PPD prevalence rates range from 2.1% in Zurich, Switzerland, to 31.6% in Bordeaux, France.2

Back to Article Outline

DEFINITION 

Postpartum affective disorders can be divided into three main categories: postpartum blues, PPD, and postpartum psychosis. Postpartum blues is the most common, with a prevalence of 40% to 80%. Postpartum psychosis is rare, with a prevalence rate of 0.1% to 0.2%.3, 4 A comparison of the three disorders is shown in Table 1.3, 4, 5, 6

Table 1. Comparison of Postpartum Affective Disorders
DisorderOnset and DurationSymptomsTreatment
Postpartum BluesOnset is 3-4 d postpartum and can last 12 h to 2 wkRapid but mild mood swings, irritability, tearfulness, anxiety, and insomniaNo treatment required, except support and reassurance
Postpartum DepressionOnset is within 6-12 mo postpartum and can last weeks to monthsMore extreme disturbances in appetite, sleep, and libido; intense anxiety, fatigue, and/or feelings of guiltCounseling, therapy, medication, or combination usually required by health care professional
Postpartum PsychosisOnset is up to 2 wk postpartum and can last weeks to monthsSymptoms are severe and include disorganized behavior, rapid mood swings, delusions, and hallucinationsHospitalization usually required

Back to Article Outline

RISK FACTORS 

Research has shown that many cases of PPD begin during pregnancy; therefore, being aware of the risks is essential to tailoring patient-specific interventions.7 In a retrospective study of women with PPD, 50% reported that symptoms began before or during their pregnancy.8 Despite this, a systematic review of 16 studies has shown poor predictive value and sensitivity about screening tools used antenatally. No screening instruments met the criteria for antenatal screening; therefore, only postnatal use of screening tools is recommended.9 Conversely, assessment of patients' past psychosocial and medical history antenatally is helpful in identifying mothers at greater risk and is still warranted.

A synthesis of three meta-analyses about risk factors for PPD concluded the strongest risk factors for postpartum depression are as follows: depression during pregnancy, anxiety during pregnancy, life events such as losing a job or divorce, and past history of psychiatric illness.10 Inadequate social support, childcare-related stressors, and poor quality relationship with a partner have been consistent predictors of PPD, whereas low socioeconomic status and difficult infant temperament have not been upheld as consistent predictors of PPD.11, 12 Cultural groups in India, China, and Nigeria have consistently found that female babies are looked down on, and this gender bias may increase the risk of PPD in mothers with female babies.2, 13, 14

Back to Article Outline

CAUSE 

The cause of PPD is unknown, but research suggests the cause is multifactorial. The National Mental Health Association (NMHA) describes the cause of PPD as a composite of three interrelated factors: hormone fluctuations, situational risk, and life stresses.11 On the basis of the information from the NMHA, we have developed the triad of pathogenesis shown in Figure 1. The hormone fluctuations noted in the triad involve decreased serotonin and estrogen levels after delivery. Examples of situational risks include a death in the family, divorce, or loss of a job. Life stresses that may also lead to the development of PPD include balancing career and motherhood, loss of former roles or freedoms, relationship stresses, and unresolved feelings about the pregnancy.11, 15

Back to Article Outline

CLINICAL MANIFESTATIONS 

In general, the clinical manifestations of PPD include severe changes in sleeping, eating, and activity patterns. For example, a woman may not be able to sleep even when her baby is sleeping, or she may sleep excessively. A woman with PPD may tell you she forces herself to eat or her lack of energy makes her unable to care for herself or the infant.5, 16 Additional symptoms to look for include anxiety, intense irritability or anger, feelings of guilt, a sense of being overwhelmed, feelings of being a failure as a mother, and changes in libido that exceed what is expected.

In a study in which the Postpartum Depression Screening Scale (PDSS) was used, three leading symptom dimensions were identified: emotional lability, mental confusion, and anxiety/insecurity.17 Anxiety, weight loss, and agitation are all symptoms of PPD but may also be due to other medical conditions such as anemia or thyroid disorders.17, 18 Anemia may result from excessive loss of blood during delivery or poor nutrition during pregnancy, resulting in symptoms of extreme fatigue and diminished concentration. The APN may be able to rule out various causes such as hypothyroidism or hyperthyroidism, drug abuse, or anemia by ordering thyroid studies, a urine drug screen, or a complete blood count.19 The challenge for the provider is to determine which symptoms are significant and which are associated with normal physical, situational, and psychological postpartum changes. Screening tools have been designed to aid clinicians in this process.

Back to Article Outline

SCREENING 

The responsibility of the APN is to ensure that screening occurs and is followed by a referral to the appropriate professional. If the APN is qualified and comfortable managing PPD, a referral to a psychiatric mental health nurse practitioner (PMH-NP) or psychiatrist for diagnosis is not warranted.16 Screening tools are necessary to identify PPD as a mood disorder (major depressive, manic, or mixed episode) according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). The DSM-IV does not recognize PPD as a diagnosis alone. For example, it would be classified as major depressive episode with a “postpartum onset specifier,” which labels the mood disorder as occurring within 4 weeks postpartum.20 The diagnostic criteria necessary to diagnose PPD as a major depressive episode with postpartum onset specifier is given in Table 2. For episodes that present later, there is no onset specifier.

Table 2. Major Depressive Episode
Diagnostic Criteria
Five or more of the following symptoms must be present for at least 2 weeks; at least one of the symptoms must be depressed mood or loss of interest or pleasure.
Depressed mood nearly every day

Diminished interest or pleasure in most all activities nearly every day

Weight loss > 5% of body weight in 1 month

Insomnia or hypersomnia

Psychomotor retardation or agitation

Fatigue or loss of energy nearly every day

Feelings of worthlessness and excessive guilt

Diminished ability to concentrate or think nearly every day

Recurrent thoughts of death; may have with suicidal ideation, attempt, or plan

Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000. Reprinted with permission.

Two highly recommended screening tools are the PDSS and the Edinburgh Postnatal Depression Scale (EPDS). The PDSS was developed by Beck and Gable with the intent of identifying PPD.21 (The PDSS and its psychometric manual can be obtained through Western Psychological Services in Los Angeles [www.wpspublish.com]. The scale and manual can be purchased at this website.) In a comparative analysis of multiple instruments, the PDSS has achieved the highest sensitivity and specificity at 94% and 98%, respectively.22 The PDSS has seven dimensions and comprises 35 questions. The dimensions are as follows: sleeping/eating disturbances, anxiety/insecurity, emotional liability, mental confusion, loss of self, guilt/shame, and suicidal thoughts. The responses are ranked on a Likert scale from 1 (strongly disagree) to 5 (strongly agree). A score of 60 to 79 identifies women with a positive screen for minor depression, and a score of 80 or above represents a positive screen for major PPD.21

The second instrument, the EPDS, was developed specifically to screen for depressive symptoms during the postpartum period. (The EPDS can be printed free from health.utah.gov/rhp/pdf/EPDS.pdf.) The EPDS is a self-report, 10-question instrument that has been used in many countries.23 It has a sensitivity and specificity of 86% and 78%, respectively. The EPDS has proven valid in numerous studies and is now computerized and translated into more than 12 languages.24 The EPDS is written at a fourth to fifth grade reading level and has been successful in identifying PPD regardless of socioeconomic status.24 Responses are scored 0 to 3 with a maximum score of 30. A score greater than 12 will identify most women with PPD. This screening tool can be easily administered and scored within 5 minutes.

Back to Article Outline

SCREENING SETTINGS 

Screening for PPD is not limited to the obstetric and gynecologic setting, although this is the first and most common setting. APNs in an obstetric practice may see a patient anywhere from 2 to 6 weeks postpartum and then not again for another year or more. Symptoms of PPD may appear any time during the first 6 to 12 months postpartum.11 The pediatric office is the second setting where a PPD screening should take place. The APN who works in pediatrics has the opportunity to evaluate a mother five or six times, during the first 6 months postpartum, at well-baby visits. The APN in pediatrics also has the opportunity to see how a mother communicates verbally and nonverbally with her baby. The APN in the pediatric setting should look for mothers that appear withdrawn or have a sad, flat affect when interacting with the baby.15 An example of PPD identified in this setting may be a mother 8 weeks postpartum who is critical and hostile toward her infant.15

APNs in the pediatric setting should have a dedicated screening tool, such as the PDSS or EPDS, to evaluate mothers at every visit. The PPD screening at the pediatric office may be the first and only screening a new mother receives. If PPD is suspected by the APN in pediatrics, it is recommended that the mother be referred to her own primary care provider to rule out other medical conditions. However, it would be appropriate to see the mother and her baby again in 2 weeks in the pediatrician's office if PPD is suspected.15 Frequent follow-up by phone and in the office should never be considered overaggressive or inconvenient; instead, it should be considered supportive. Research findings have shown that professional or social support is beneficial in the treatment of PPD.15

The third setting for screening is the family or adult primary care office. Women with PPD may be referred to their APN or physician in this setting to rule out PPD versus another medical condition. Additionally, women may be seen for an annual examination or a sick visit and this may be the first and only screening they receive. The mother's primary care provider may have the advantage of knowing the mother very well, allowing for deviations from baseline to be detected more easily. A broad differential diagnosis (Table 3) should always be considered before developing a management plan.16, 19

Table 3. Differential Diagnosis
Postpartum blues
Postpartum depression
Postpartum psychosis
Anxiety disorder
Substance abuse disorder
Hypothyroidism
Hyperthyroidism
Anemia

Back to Article Outline

NONPHARMACOLOGIC AND PHARMACOLOGIC TREATMENT 

Both nonpharmacologic and pharmacologic options have shown merit. Nonpharmacologic treatment includes cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family and marital group therapy, psychodynamic therapy (PDT), electroconvulsive therapy, peer-support groups, and light therapy.19, 25, 26, 27 In a randomized controlled study, PDT was found to be significantly superior to CBT, IPT, nondirective counseling, and the usual care group at lowering EPDS scores.25 In other studies, IPT and mother and infant group therapy have also shown statistically significant benefit over the control group as treatments of PPD.26 In a study of 146 women randomly assigned to group CBT, individual CBT, group behavior therapy, and medication group, both CBT and group behavior were found to be equally effective in treating PPD.27

A few studies have shown that pharmacologic treatment has been equally effective as CBT and nonspecific counseling, and the combination of pharmacologic and nonpharmacologic treatments has not shown additional benefit.27, 28 Pharmacologic treatments were proven successful in the treatment and resolution of symptoms related to PPD. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitor (SNRIs) are considered first-line medications.1, 16, 27, 28 Dosing recommendations are given in Table 4, and a case study that shows how this information may be used is given in Box 1. If improvement does not occur within 6 weeks or the patient responds but then relapses, a referral to a PMH-NP or psychiatrist must be made.1 The American Psychiatric Association recommends that to prevent relapse successful pharmacologic treatment should be continued 6 months after a full remission has been reached.20

Table 4. Antidepressant Dosage Recommendations
DrugLactation Risk Category*Starting Dose, mg/dUsual Therapeutic Dose, mg/dUsual Dose, mg/d
SSRIs
Paroxetine (Paxil)L22020-6020-60
Paroxetine CR (Paxil)L212.525-37.525-75
Citalopram (Celexa)L32020-6020-60
Escitalopram (Lexapro)L3 in older infants1010-2010-20
Sertraline (Zoloft)L25050-20050-200
Fluoxetine (Prozac)L2 older infants2020-4020-60
L3 neonates
SNRIs
Venlafaxine XR (Effexor)L337.575-30075-300

CR, controlled release; XR, extended release.

Data from Hale31 and Misri and Luskin.16

* Lactation risk categories include L1, safest; L2, safer; L3, moderately safe; L4, possibly hazardous; and L5, contraindicated.31

Box 1. Case Study

Beth is a 26-year-old white female, G2, P0-0-1-0, with a history of a spontaneous miscarriage at 16 weeks 1 year ago. Beth has no past medical or psychiatric history. Her family history is unremarkable. Beth's social history is significant for recently being laid off from work, which is putting stress on the newly married couple's relationship because her husband is only working part time while going to graduate school. Beth has reported fears that she will be caring for this child on her own because her husband is so busy. Additionally, they moved to Boston for her husband's graduate program, away from both families. Beth's nurse practitioner (NP) referred her to a social worker at the local community outreach center during her sixth month of pregnancy when Beth was laid off.

Beth delivered a healthy baby boy and is now 7 weeks postpartum. She has come to see her NP for a postpartum visit and was screened using the PDSS. Beth's score of 78 was positive for PPD. At the visit the NP noted Beth to be slightly anxious and poorly groomed compared with other prenatal visits. Beth reported, “I just can't keep up with the baby's needs, and my husband gives me no support. He just tells me I need to start eating and sleeping and to stop worrying.” Beth had stopped breast-feeding and reported being tired all the time but could not sleep. Beth said, “Sometimes I think about running away and leaving my husband with the baby; maybe he could handle it better.”

After a thorough physical examination, the NP informed Beth that she thought she had PPD. The NP evaluated Beth for any signs of suicidal or homicidal ideation to determine whether this was a medical emergency, and it was not. The NP explained to Beth that PPD was not her fault and was a medical disorder just as common as gestational diabetes. She informed Beth that it may be a good idea to see her primary care provider to rule out any other causes for her depression.

At this point the NP started Beth on sertraline 50 mg daily and clonazepam 0.5 mg every evening as needed. Beth was also instructed on some low-cost nonpharmacologic treatments such as exercising with the baby in the sun and joining a local support group. The NP also gave Beth some additional resources so that she could do further reading or seek other options.

Symptoms commonly seen in PPD may also be side effects of SSRIs, such as anxiety, jitteriness, agitation, headache, and gastrointestinal symptoms.17, 18 These side effects can be alleviated by adding low-dose benzodiazepines such as clonazepam 0.5 to 1 mg. Other side effects of SSRIs and SNRIs include decreased libido and difficulty achieving orgasm.29

Pharmacologic management for breast-feeding mothers is complicated because the benefits to the mother must be weighed against the harms that may be done to the child. This can pose an ethical dilemma, which should be addressed on a case-by-case basis. Research findings have shown that SSRIs are generally safe during breast-feeding, but none can be unequivocally recommended. Sertraline, venlafaxine extended release, and paroxetine were not shown to have adverse effects on breast-fed infants in limited studies.30 Fluoxetine and citalopram produced the highest proportion of infants with detectable levels.30

The following should be considered when selecting a drug management plan for any breast-feeding mother:

•The woman's previous response to antidepressant medications

•The anticipated efficacy and response of the woman

•How the side effect profile will be handled by each individual woman

•What medications she is currently taking to avoid interaction

•What are the potential adverse effects for the mother and infant30

In the breast-feeding mother, always consider nonpharmacologic alternative therapies such as massage, exercise, diet, light, and wake therapy. Nonpharmacologic therapies will eliminate any infant drug exposure.

Back to Article Outline

CONCLUSION 

The following clinical practice recommendations are made to all APNs encountering postpartum women. APNs must familiarize themselves with the risk factors and the multifactorial causes of PPD. The APN in women's health should always assess social support at prenatal visits and provide education on PPD. The APN should obtain a validated PPD screening tool such as the PDSS or the EPDS to use in the pediatric, obstetric, gynecologic, or family practice setting. All postpartum women, regardless of the setting, must be screened through the first 12 months postpartum.11

It is necessary to develop a file with up-to-date resources that can be provided to patients who need assistance. Patients who need psychological or behavior therapy, pharmacotherapy, and those with a history of PPD should be referred to a PMH-NP or psychiatrist.16 Send any woman with suicidal or homicidal ideation directly to the closest emergency room, because this is considered a medical emergency.

The APN must be familiar with the treatments used for PPD, such as SSRIs, SNRIs, and nonpharmacologic therapies. In breast-feeding mothers, sertraline, venlafaxine extended release, and paroxetine were shown to be relatively safe. However, it is always necessary to individualize treatment plans. Women's health care providers can refer patients to the appropriate management team or, if qualified, begin treatment. Some resources that patients and professionals may find helpful are given in Box 2.

Box 2. Resources

For Parents

Postpartum Education for Parents

805-564-3888

www.sbpep.org

Postpartum Support International

1-800-773-6667

www.postpartum.net

National Women's Health Information Center

1-800-944-WOMAN (9662)

www.4woman.gov/faq/postpartum.htm

For Professionals

National Institute of Mental Health

301-496-9576

www.nimh.nih.gov

American College of Nurse Midwives

www.midwife.org

Early identification can reduce the rate of morbidity and mortality and can improve overall outcomes for the mother and her baby.32 It is unknown how many cases of PPD go undiagnosed, but it is presumed to be many, because women continue to lose their lives to this disease. Many women are left to suffer in silence because of the societal stigma of mental illness or the neglect of practitioners in screening. APNs are trained to provide comprehensive care, which demands an assessment of patients' mental and emotional well-being, in addition to their physical condition.

Back to Article Outline

References 

  1. Wisner KL , Parry BL , Piontek CM . Clinical practice. Postpartum depression . N Engl J Med . 2002;347(3):194–199
  2. Gorman LL , O'Hara MW , Figueiredo B , et al.   Adaptation of the structured clinical interview for DSM-IV disorders for assessing depression in women during pregnancy and postpartum across countries and cultures . Br J Psychiatry . 2004;184(suppl 46):17–23
  3. Steiner M . Postpartum psychiatric disorders . Can J Psychiatry . 1990;35(1):89–95
  4. O'Hara MW , Schlechte JA , Lewis DA , Wright EJ . Perspective study of postpartum blues. Biologic and psychosocial factors . Arch Gen Psychiatry . 1991;48(9):801–806
  5. Nonacs R , Cohen LS . Postpartum mood disorders. Diagnosis and treatment guidelines . J Clin Psychiatry . 1998;59(suppl 2):34–40
  6. Kendell RE , Chalmers JC , Platz C . Epidemiology of puerperal psychoses . Br J Psychiatry . 1987;150:662–673
  7. Stowe ZN , Hostetter AL , Newport DJ . The onset of postpartum depression. Implications for clinical screening in obstetrical and primary care . Am J Obstetr Gynecol . 2005;192(2):522–526
  8. Yonkers KA , Ramin SM , Rush AJ , et al.   Onset and persistence of postpartum depression in an inner city maternal health clinic system . Am J Psychiatry . 2001;158(11):1856–1863
  9. Austin MP , Lumley J . Antenatal screening for postnatal depression. A systematic review . Acta Psychiatr Scand . 2003;107(1):10–17
  10. Robertson E , Grace S , Wallington T , Stewart DE . Antenatal risk factors for postpartum depression. A synthesis of recent literature . Gen Hosp Psychiatry . 2004;26(4):289–295
  11. National Mental Health Association  . Postpartum Disorders . Available at: www.nmha.org 2005; Accessed September 5, 2005
  12. Beck CT . Predictors of postpartum depression. An update . Nurs Res . 2001;50(5):275–285
  13. Chandran M , Tharyan P , Muliyil J , Abraham S . Postpartum depression in a cohort of women from a rural area of Tamil Nadu, India . Br J Psychiatry . 2002;181:495–504
  14. Adewuya AO . The maternity blues in western Nigerian women. Prevalence and risk factors . Am J Obstetr Gynecol . 2005;193(4):1522–1525
  15. Currie ML , Rademacher R . The pediatrician's role in recognizing and intervening in postpartum depression . Pediatr Clin North Am . 2004;51(3):785–801
  16. Misri S , Luskin SI . Postpartum blues and depression. UpToDate 2005 . Available at: www.uptodate.com Accessed November 28, 2005
  17. Beck CT , Indman P . The many faces of postpartum depression . J Obstetr Gynecol Neonatal Nurs . 2005;34(5):569–576
  18. Heron J , O'Connor TG , Evans J , Golding J , Glover V , the ALSPAC study team  . The course of anxiety and depression through pregnancy and the postpartum in a community sample . J Affective Dis . 2004;80(1):65–73
  19. Epperson CN . Postpartum major depression: detection and treatment . Am Fam Physician . 1999;59(8):2247–2254 2259-2260
  20. American Psychiatric Association  . Diagnostic and statistical manual of mental disorders . 4th ed.. Washington, DC: American Psychiatric Association; 1994;
  21. Beck C , Gable R . The postpartum depression screening scale manual . Los Angeles, Calif: Webster Psychological Association; 2002;
  22. Beck C , Gable R . Comparative analysis of the performance of the postpartum depression screening scale with two other depression instruments . Nurs Res . 2001;50(4):242–250
  23. Cox J , Holden J , Sagovsky R . Detection of postnatal depression: development of the Edinburgh Postnatal Depression Scale . Br J Psychiatry . 1987;150:782–786
  24. Murray L , Carothers AD . The validation of the Edinburgh postnatal depression scale on a community sample . Br J Psychiatry . 1990;157:288–290
  25. Cooper PJ , Murray L , Wilson A , Romaniuk H . Controlled trial of the short and long term effect of psychological treatment of postpartum depression. Impact on maternal mood . Br J Psychiatry . 2003;182:412–419
  26. Clark R , Tluczek A , Wenzel A . Psychotherapy for postpartum depression. A preliminary report . Am J Orthopsychiatry . 2003;73(4):441–454
  27. Highet N , Drummond P . A comparative evaluation of community treatments for postpartum depression: implications for treatments and management practices . Aust N Z J Psychiatry . 2004;38(4):212–218
  28. Appleby L , Warner R , Whitton A , Faragher B . A controlled study of fluoxetine and cognitive counseling in the treatment of postnatal depression . BM J . 1997;314(7085):932–936
  29. Ashton AK , Rosen RC . Bupropion as an antidote for serotonin reuptake inhibitor induced sexual dysfunction . J Clin Psychiatry . 1998;59(3):112–115
  30. Misri S , Luskin SI . Use of psychotropic medications in breastfeeding women. UpToDate 2005 . Available at: www.uptodate.com Accessed November 28, 2005
  31. Hale T . Medications and Mothers' Milk . Amarillo, TX: Pharmasoft Publishing; 2004;
  32. Beck CT . Postpartum depressed mothers' experience interacting with their children . Nurs Res . 1996;45(2):98–104

PII: S1555-4155(06)00156-5

doi:10.1016/j.nurpra.2006.02.008

The Journal for Nurse Practitioners
Volume 2, Issue 4 , Pages 247-253, April 2006

Article Tools

* Image Usage & Resolution