Chapter 30 POSTPARTUM DEPRESSION

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, major depression is defined by the presence of five of the following symptoms, one of which must be either depressed mood or decreased interest or pleasure in activities:

The psychiatric postpartum experiences usually are divided into three categories: “maternal blues,” postpartum depression, and postpartum psychosis.

“Maternal blues,” also known as the “baby blues,” is a transient state of heightened emotional reactivity that occurs in up to 85% of new mothers. Symptoms such as weeping, sadness, anxiety, irritability, and confusion occur, peaking around the 4th postpartum day and resolving by the 10th day.

Postpartum depression is a clinical term referring to a major depressive episode that is temporally associated with childbirth. An episode of depression is considered to have postpartum onset if it begins within 4 weeks after delivery. However, most investigators and clinicians use a time frame from 24 hours to 6 months after delivery to define postpartum depression. In fact, depressive episodes at any time within the first year after delivery may also be considered being postpartum in onset.

Postpartum depression occurs in approximately 10% to 20% of women in the United States within 6 months of delivery.

Postpartum psychosis occurs in 0.2% of childbearing women and usually begins during the first 4 weeks after delivery. The psychosis is typically manic in nature and in most cases may be considered a manifestation of bipolar disorder. Early warning signs include insomnia for several nights, agitation, an irritable or expansive mood, and avoidance of the infant. When delusions or hallucinations are present, they often involve the infant. Postpartum psychosis is considered a medical emergency because the affected woman is at risk for harming herself or her baby.

If the patient has considered a plan to act on suicidal thoughts or has thoughts about harming her infant, provisions for safety and urgent referral for psychiatric care are recommended.

The Edinburgh Postnatal Depression Scale (Table 30-1) is a 10-item questionnaire that is an effective screening tool for postpartum depression. A cutoff score of 9 or 10 has been recommended as a reliable indicator for the presence of postpartum depression in women in the United States. A clinical interview to review symptoms and establish the diagnosis of depression is warranted. A score between 5 and 9 should be evaluated again 2 to 4 weeks later in order to determine whether an episode of depression has evolved or whether symptoms have subsided.

Table 30-1. Edinburgh Postnatal Depression Scale.

(From Cox JL, Holden JM, Sagovsky R: Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-786)

Other postpartum depression screening tools include the Postpartum Depression Checklist, the Beck Depression Inventory, and the Center for Epidemiologic Studies Depression Scale.

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