SOAP. – Postpartum Depression – SỔ TAY LÂM SÀNG

Postpartum Depression

Christina C. Reed and Susan Drummond

Definition

A.Postpartum depression is a mood disorder characterized by unexplained tearfulness, sadness, irritability, and disturbances in appetite and sleep patterns, as well as an inability to care for self or baby, usually presenting within 2 weeks to 3 months postpartum.

Incidence

A.Reported incidence in the United States is between 8% and 15%.

Pathogenesis

A.It is believed that postpartum depression may be related to psychological, physiologic, and cultural factors. The extreme hormonal changes that occur during the postpartum period may contribute. Postpartum thyroiditis is also a suspected factor. However, no confirmed biologic cause has been found. Some authorities have suggested that the mother’s feeling of loss of control over her own life is the underlying precipitating factor.

Predisposing Factors

The following may make a mother more likely to experience postpartum depression:

A.Preterm infant.

B.Multiple gestation.

C.Maternal and/or fetal complications in pregnancy.

D.History of postpartum depression or mental health conditions.

E.Social stressors: Dissatisfaction in the marriage, financial difficulties, and lack of support in the home.

F.Age younger than 20 years.

G.Single parent.

H.Poor relationship with the father of the baby.

I.Evidence of significant emotional problems in the past.

J.Having experienced separation from one or both parents during childhood or adolescence.

K.Having received poor parental support and attention in childhood or having limited social support in adulthood.

L.Low self-esteem.

Common Complaints

A.Insomnia.

B.Poor appetite.

C.Tearfulness.

D.Fatigue.

E.Anxiety.

F.Headaches.

G.Difficulty concentrating or confusion.

H.Feelings of excessive guilt or worthlessness.

I.Possible suicidal ideations.

Other Signs and Symptoms

A.Mood swings.

B.Despondency, social withdrawal, and feeling of inadequacy.

C.Guilt.

D.Impaired memory.

E.Ambivalence about motherhood and baby.

F.Inability to care for self and baby.

G.Poor grooming of self and/or baby.

Subjective Data

A.Elicit onset, duration, and course of symptoms.

B.Review the patient’s medical history for predisposing factors.

C.Question the patient regarding her ability to care for her infant, herself, and other family members at home.

D.Review the amount of support in the home. Is she the primary caregiver? Are there any family members or friends who help in household management, sibling child care, and newborn care?

E.Does the patient get out of bed and dress herself daily?

F.Does the patient have thoughts of harming the infant, herself, or others?

Physical Examination

A.Check temperature (if indicated), pulse, respirations, and BP.

B.Inspect:

1.Note general overall appearance, including dress, makeup, neatness of hair, tearfulness, and apathy.

2.Observe her interaction with the baby, for example, talking to the baby and tone of voice, eye contact, and so on.

C.Postpartum examination (see Exhibit 16.1).

Diagnostic Tests

A.The Edinburgh Postnatal Depression Scale (EPDS) should be completed at every postpartum visit (see Exhibit 16.2). The EPDS is available for download at www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.

1.Scoring:

a.Add up the numbers associated with the answer that was underlined.

b.If the total is above 10 then possible depression exists; advise her to seek behavior health.

c.Always look at question 10 on suicidal thoughts; if the patient answers anything other than Never, advise behavior health appointment and assess if assistance is needed immediately.

B.If depression is diagnosed, a thyroid profile should be ordered.

Differential Diagnoses

A.Postpartum depression.

B.Baby blues: Tearfulness, insomnia, fatigue, headaches, poor appetite, and so on; appearing between the birth and 14 postpartum days.

C.Postpartum psychosis: Extreme emotional lability, agitation, delusions, hallucinations, and sleep disturbances.

D.Postpartum panic disorder: Extreme anxiety, fear, tightness in the chest, and increased heart rate.

E.Postpartum obsessive-compulsive disorder: Obsessive thoughts of harming the child, exaggerated fear of being left alone with the infant, anxiety, depression, and/or unnecessarily vigilant protectiveness of the infant.

F.Bipolar disorder.

Plan

A.General interventions:

1.Assess all patients for mood disorders at all postpartum points of contact telephonic or in person.

2.Early assessment and treatment is very important. Symptoms that are not treated for several weeks may get progressively worse. Patients with severe depression, characterized by suicidal or homicidal ideation, aggressive behavior, delusions, hallucinations, catatonia, poor judgment, or grossly impaired functioning, are typically hospitalized.

3.Encourage involvement of the patient’s partner and immediate family members in the counseling sessions to assist them in learning ways to assist the patient effectively.

4.If postpartum depression is diagnosed, perform serum thyroid levels.

B.Patient teaching:

1.Advise the patient that she is not to blame for the condition, that it is not uncommon, and that

successful treatment is likely.

2.Discuss participation in a support group, interpersonal psychotherapy, and cognitive behavioral therapy.

3.If antidepressants are prescribed, advise the patient that the medication may take 4 to 6 weeks for peak effect. Review benefits/risks/side effects of the medication prescribed. The risk of suicide may increase after beginning antidepressants; therefore, a follow-up appointment in 1 to 2 weeks is recommended.

C.Pharmaceutical therapy:

1.Antidepressants may be ordered for women with moderate to severe symptoms of depression when physical and emotional functioning have been compromised. (Refer to the section Depression in Chapter 25.)

2.Base selection of medication on whether or not the patient is breastfeeding. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants are commonly used and generally considered safe for breastfeeding infants:

a.Citalopram (Lexapro) in a single daily dose, usually taken in the morning. Initial dose 10 mg/d; dosage can be increased at intervals of 1 week to 20 mg. Excreted in breast milk; potential toxicity. Consider the risks and benefits before starting the medication while breastfeeding.

b.Sertraline (Zoloft) 50 mg in a single dose at bedtime. Dosage can be increased by 25 mg at 1 week intervals and not to exceed 200 mg per day. Enters into breast milk; potential toxicity. Use caution while breastfeeding.

c.Amitriptyline (Elavil) 75 mg/d in divided doses. Dosage can be increased up to 150 mg/d. Potential toxicity; not recommended while breastfeeding.

EXHIBIT 16.1 Postpartum Examination

Date: ________________________

History: Age: ____________ G ____________ PT ____________ P ____________ A ____________ L ____________

Labs: Blood type and Rh: ____________ If negative, was RhoGAM workup done and RhoGAM given in the hospital, if needed? ________________________

Rubella: ____________ If nonimmune, was she immunized before hospital discharge? ________________________

Discharge Hct: ________________________

Medical and antepartum complications: ________________________

Intrapartum course/complications: ________________________

Delivery: Date: ____________ Type: ____________ Sex: ____________ Birth weight: ________________________

Apgars: 1 minute: ____________ 5 minutes: ____________ Neonatal: Gestational age: ________________________

Complications: ________________________

Feeding: Breast/bottle: ____________ Current infant status: ________________________

Surgery: BTL: Yes/No ________________________________________________________________

If yes, pathology report reviewed: Postpartum complications: ________________________

Current status: Medical problems: ________________________

Sexual intercourse since delivery/problems: ________________________

Psychosocial/postpartum depression: ________________________

Medications: ________________________

Physical exam: BP: ____________ Pulse: ____________ Resp: ____________ Weight: ________________________

Breasts: ________________________

Pelvic: Episiotomy or laceration: ________________________

Abdomen: ________________________

Adnexa: ________________________

Uterus: ________________________

Vagina: ________________________

Cervix: ________________________

Pap smear: Date/results: ________________________

Plan: Current contraception and desired contraception: ________________________

Referrals: Labs: ________________________

New prescriptions: ____________ Patient Teaching Guides: ________________________

Pap smear follow-up: ________________________

Well woman exam with breast exam follow-up: ________________________

Other: ________________________

Signature: ________________________

BTL, bilateral tubal ligation; Hct, hematocrit; RhoGAM, Rho(D) immune globulin.

Follow-Up

A.If the patient had risk factors for depression noted prior to delivery, a follow-up office visit 3 to 4 days after hospital discharge is suggested.

B.Frequent telephone contact, or several repeat visits, may be necessary during the course of the depression until the symptoms have improved.

C.The risk of suicide may increase after beginning antidepressants; therefore, a follow-up appointment in 1 to 2 weeks is recommended.

D.Assess the patient for suicidal ideation and child neglect at every contact.

Consultation/Referral

A.Assess the need to refer the patient to a psychiatrist, psychologist, or family counselor.

B.Refer to group therapy, interpersonal psychotherapy, and/or cognitive behavioral therapy.

C.Consult a psychiatrist about alternative treatments if no change in signs and symptoms is seen.

Resources

Pacific PostPartum Support Society: www.postpartum.org.

Postpartum Support International: www.postpartum.net or 1-800-944-4773.

Postpartum Support Line: (604) 255-7999.

EXHIBIT 16.2 Edinburgh Postnatal Depression Scale

Name: ___________________ Address: ___________________

Your Date of Birth: ___________________ ___________________

Baby’s Date of Birth: ___________________ Phone: ___________________

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

Here is an example, already completed.

I have felt happy:

Yes, all the time
Yes, most of the time	This would mean: “I have felt happy most of the time during the past week.
No, not very often	Please complete the other questions in the same way.
No, not at all

In the past 7 days: 1.I have been able to laugh and see the funny side of things As much as I always could Not quite so much now Definitely not so much now Not at all 2.I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all *3.I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never 4.I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often *5.I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not at all *6.Things have been getting on top of me Yes, most of the time I haven’t been able to cope at all Yes, sometimes I haven’t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever *7.I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all *8.I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all *9.I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never *10.The thought of harming myself has occurred to me Yes, sometimes Sometimes Hardly ever Never Administered/Reviewed by: ___________________ Date: ___________________ Instructions for using the Edinburgh Postnatal Depression Scale: A.The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days. B.All the items must be completed. C.Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.) D.The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

EPDS, Edinburgh Postnatal Depression Scale. Postpartum depression is the most common complication of childbearing. The 10-question EPDS is a valuable and efficient way of identifying patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective screening tool. Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders. Women with postpartum depression need not feel alone. They may find useful information on the websites of the Office on Women’s Health <www.womenshealth.gov/mental-health/mental-health-conditions/postpartum-depression> and from groups such as Postpartum Support International <www.postpartum.net> and PostpartumDepression.org <www.postpartumdepression.org>. Sources: Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. doi:10.1192/bjp.150.6.782; Wisner, K. L., Parry, B. L., & Piontek, C. M. (2002, July 18). Postpartum depression. New England Journal of Medicine, 347 (3), 194–199. doi:10.1056/NEJMcp011542; Edinburgh Postnatal Depression Scale (n.d.). Retrieved from www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.

In the past 7 days:

1.I have been able to laugh and see the funny side of things

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

2.I have looked forward with enjoyment to things

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

*3.I have blamed myself unnecessarily when things went wrong

Yes, most of the time

Yes, some of the time

Not very often

No, never

4.I have been anxious or worried for no good reason

No, not at all

Hardly ever

Yes, sometimes

Yes, very often

*5.I have felt scared or panicky for no very good reason

Yes, quite a lot

Yes, sometimes

No, not much

No, not at all

*6.Things have been getting on top of me

Yes, most of the time I haven’t been able to cope at all

Yes, sometimes I haven’t been coping as well as usual

No, most of the time I have coped quite well

No, I have been coping as well as ever

*7.I have been so unhappy that I have had difficulty sleeping

Yes, most of the time

Yes, sometimes

Not very often

No, not at all

*8.I have felt sad or miserable

Yes, most of the time

Yes, quite often

Not very often

No, not at all

*9.I have been so unhappy that I have been crying

Yes, most of the time

Yes, quite often

Only occasionally

No, never

*10.The thought of harming myself has occurred to me

Yes, sometimes

Sometimes

Hardly ever

Never

Administered/Reviewed by: ___________________ Date: ___________________

Instructions for using the Edinburgh Postnatal Depression Scale:

A.The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days.

B.All the items must be completed.

C.Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.)

D.The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

EPDS, Edinburgh Postnatal Depression Scale.

Postpartum depression is the most common complication of childbearing. The 10-question EPDS is a valuable and efficient way of identifying patients at risk for perinatal depression. The EPDS is easy to administer and has proven to be an effective screening tool. Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders.

Women with postpartum depression need not feel alone. They may find useful information on the websites of the Office on Women’s Health <www.womenshealth.gov/mental-health/mental-health-conditions/postpartum-depression> and from groups such as Postpartum Support International <www.postpartum.net> and PostpartumDepression.org <www.postpartumdepression.org>.

Sources: Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. doi:10.1192/bjp.150.6.782; Wisner, K. L., Parry, B. L., & Piontek, C. M. (2002, July 18). Postpartum depression. New England Journal of Medicine, 347 (3), 194–199. doi:10.1056/NEJMcp011542; Edinburgh Postnatal Depression Scale (n.d.). Retrieved from www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.

Postpartum Depression

Definition

Incidence

Pathogenesis

Predisposing Factors

Common Complaints

Other Signs and Symptoms

Subjective Data

Physical Examination

Diagnostic Tests

Differential Diagnoses

Plan

EXHIBIT 16.1 Postpartum Examination

Follow-Up

Consultation/Referral

Resources

EXHIBIT 16.2 Edinburgh Postnatal Depression Scale

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