Ppd postpartum depression

1. POSTPARTUM DEPRESSION
BEYOND THE BLUES

2. INCIDENCE OF DEPRESSION
Each year, 15% to 20% of adults in the
United States experience a major depression
The incidence among women is twice that
of men and peaks between 18 to 44 years of
age - the childbearing years

3. DEPRESSION IN WOMEN
Women are at increased risk of mood
disorders during periods of hormonal
fluctuation-
premenstrual
postpartum
perimenopausal

4. THE RANGE OF POST-
DELIVERY MOOD
DISORDERS
50% to 80% of women experience transient
“baby blues” within the first two weeks
following delivery
0.1% to 0.2% of women experience
postpartum psychosis usually within the
first 4 weeks following delivery

5. POSTPARTUM DEPRESSION
6.8% to 16.5% of women experience
postpartum depression (PPD) also known as
postpartum major depression (PMD)
Onset can be as early as 24 hours or as late
as several months following delivery

6. SYMPTOMS OF
POSTPARTUM DEPRESSION
Hopelessness Loss of pleasure in activities
Helplessness Mood changes
Persistent sadness Inability to adjust to role of
motherhood
Irritability Inability to concentrate
Low self-esteem Sleep /appetite disturbances

7. RANGE OF SYMPTOMS
Symptoms range-
from mild dysphoria
to suicidal ideation
to psychotic depression

8. DURATION OF SYMPTOMS
Untreated, symptoms can last:
several months
into the second year postpartum

9. THE ETIOLOGY OF
POSTPARTUM DEPRESSION
Various theories based in physiological
changes have been postulated:
hormonal excesses or deficiencies of estrogen,
progesterone, prolactin, thyroxine, tryptophan,
among others

10. ETIOLOGY OF POSTPARTUM
DEPRESSION
Other theories cite numerous psychosocial
factors associated with PMD:
marital conflict
child-care difficulties (feeding, sleeping, health
problems)
perception by mother of an infant with a
difficult temperament
history of family or personal depression

11. Higher rates of depression were
noted among women who:
Had less than a high school
education
Reported being abused before
or during pregnancy
Were less than 19 years old Had 0 to 1 person as a source
of social support
Resided in a household with
an income <$15,000
Were not married
Experienced an unintended
pregnancy
Reported 6 to 18 stresses
during pregnancy (sick family
member, divorce, etc.)

12. THE IMPACT OF
POSTPARTUM DEPRESSION

13. LONG TERM
CONSEQUENCES OF PMD
Negative impact on the infant ‘s social,
emotional and cognitive development
2 month old infants of mothers with PMD had
decreased cognitive ability and expressed more
negative emotions during testing

14. LONG TERM
CONSEQUENCES OF PMD
Babies of mothers
with PMD were
perceived by their
mothers as more
difficult to care for
and more bothersome.

15. POSTPARTUM DEPRESSION
& MATERNAL MORTALITY
In recent years, there have been two
maternal deaths due to suicide by women
within one year of giving birth.
Neither woman had been screened for
postpartum depression

16. RISK FACTORS FOR PMD
-Family history of mood
disorder
-Child-care difficulties:
feeding, sleeping, health
-Client history of mood
disorder prior to pregnancy
-Marital conflict
-Anxiety/depression during
pregnancy
-Stressful life events
-Previous postpartum
depression
-Poor social support
-Baby blues following current
delivery

17. INTERVENTIONS
SCREENING FOR PMD

18. SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
Be unable to recognize she is depressed

19. SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
Believe her symptoms are “normal” for new
moms

20. SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
Fear being labeled a “bad mother” if she
admits her maternal experience does not
meet society’s picture of bliss

21. SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
Feel she is going crazy and fears her baby
will be taken from her

22. WHEN TO SCREEN FOR PMD
At preconception visit
During prenatal intake & subsequent visits
During postpartum exams
During infant’s WCC & WIC visits
When infant is seen for sick care or in ER
At early intervention home visits
At family planning visits during the first
year postpartum
At mother’s visits for routine episodic care

23. SCREENING TOOLS
There are several tools available:
Edinburgh Postnatal Depression Scale (EPDS)
The Mills Depression & Anxiety Checklist
The Center for Epidemiological Studies
Depression Scale (CES-D)
Others, often on various websites for mental
health

24. A WORD ABOUT
SCREENING TOOLS!
Be familiar with the tool - its validity and
limitations
Have a referral network available for
women screening positive
Document the screening and any referrals
made
Follow-up with your client to assure that
she received needed assistance

25. EDINBURGH POSTNATAL
DEPRESSION SCALE (EPDS)
Designed for home or outpatient use
Consists of 10 questions
Can be completed in approx. 5 minutes
Reviews feelings the previous 7 days
Scored 0-3 depending on symptom severity
Depending on study, cut off is 13 - 9 points

26. TREATMENT
1. Educate the woman and her support
system regarding the diagnosis of
postpartum depression.

27. TREATMENT OPTIONS
Pharmacological intervention
Counseling, individual and/or group
Support groups

28. PHARMACOLOGICAL
INTERVENTION
Use of tricyclic antidepressants and
selective serotonin reuptake inhibitors
(SSRIs) may be indicated for both non-
nursing and nursing mothers
Have low incidence of infant toxicity and
adverse effects during breastfeeding*
Decisions regarding use while breastfeeding
must be on a case by case basis

29. OTHER CONSIDERATIONS:
Provider must be familiar with agents and
the hepatic function of mother and infant
Client must be informed of risks/benefits of
treatment Vs. no treatment for herself and
her infant
unknown impact of long-term use of
medications on neurodevelopment of infant

30. Other Considerations - Cont.
If the woman chooses to breastfeed while
on psychotropics, she should work
collaboratively with a psychiatrist and her
pediatrician
If the infant experiences insomnia or other
behavior changes, his serum should be
assayed for the presence of medication
Document all discussions regarding
treatment in the client’s chart

31. COUNSELING
Know referral sources in your locale,
especially those that:
accept Medicaid
utilize a sliding fee
will develop a payment plan with the client
offer free counseling
Be familiar with indigent drug programs
available through various pharmaceutical
manufacturers

32. Counseling - Cont.
Any woman with symptoms of psychosis or
with serious suicidal/homicidal ideation
should be referred for emergency
psychiatric evaluation

33. SUPPORT GROUPS
Numerous postpartum support groups are
available. Contact:
Local mental health agencies
Hospitals
Websites