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August 29, 2003
News this month Having a baby can be one of the happiest times in a woman’s life. It can also be one of the most stressful. Many physical and emotional changes occur in a woman when she’s pregnant and after she delivers a baby. Those changes can leave women feeling sad, exhausted and confused. For many women, these feelings disappear in a few days. Many physical and emotional changes occur in a woman when she’s pregnant and after she delivers a baby.
For others, however, the feelings don’t go away and, for many women, they may get worse. According to a report published in The New England Journal of Medicine, up to 13 percent of new mothers suffer from postpartum depression (PPD). Since there are nearly four million births in the U.S. annually, a half million women cope with this disorder every year. For those who have suffered previous bouts of depression, more than one in four are at risk for another episode. Lead author, Katherine Wisner, MD, a professor of psychiatry, pediatrics, obstetrics and gynecology at the University of Pittsburgh School of Medicine, said, “We wrote this article to make people aware that this is a major health problem….Women don’t need to suffer with this illness. Treatment is available and effective.” Symptoms of PPD
Postpartum depression generally begins within four weeks after delivery, but onset can be within three months after delivery. The symptoms are similar to those in women who experience depression unrelated to childbirth. Women who express any intention to harm themselves or their children should receive an urgent referral for treatment.
Diagnosing PPD Those scoring 10 or higher on the Edinburgh scale or those identified as being at risk for depression are interviewed to confirm a diagnosis and should be treated as soon as possible since the severity of PPD may increase over time. Women who express any intention to harm themselves or their children should receive an urgent referral for treatment. What causes PPD? The incidence of PPD does not appear to be related to a woman’s educational level, the sex of her baby, the type of delivery, whether the pregnancy was planned or whether or not she breastfeeds. Treatment strategies Wisner notes, however, that only one placebo-controlled clinical trial specifically addressed PPD. In that trial fluoxetine was compared with psychotherapy and both treatments were similarly effective. Fluoxetine was significantly more effective than placebo. She notes it is not certain whether specific antidepressants or classes of antidepressants are more beneficial than others. More data is needed in this critical area. Because women who have recently given birth may be highly sensitive to medications, Wisner recommends they be prescribed at half the normally recommended doses. To prevent relapse, treatment should be continued for at least six months. Because of the high incidence of recurrent bouts of depression, she suggests long-term treatment for women with three or more episodes. Some trials studying the effectiveness of psychotherapy have been promising. Wisner cites one 12-session treatment of interpersonal psychotherapy that resulted in significant improvements in functioning in treated women compared to a control group.
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 Need for screening women for perinatal depression critical While Dr. Wisner’s article cites a rate of about 13 percent of women experiencing postpartum depression, our experience suggests this number may be even higher among some populations of women. “There is a great need for patients and clinicians to be educated about the signs of both minor and major depression.”
We are participating in a project focused on screening for depression in federally and state-supported obstetrical clinics in New Haven. To date, we have screened over 1,000 women and found perinatal depression rates ranging from 20 to 25 percent. This includes women experiencing depression prior to as well as after delivery. Despite variability in estimates of depression, one thing is very clear: the number is large and there is a great need for patients and clinicians to be educated about the signs of both minor and major depression. Our research shows 25.6 percent of the women attending the clinics we studied scored positive for depression, but only 2 percent of these women were diagnosed by their health care professionals and referred for treatment. Diagnosing depression “50% of women who have had depression will have another episode and 80% of women with PPD will have a second episode.”
Screening during pregnancy makes it possible for caregivers to identify women who are at high risk for depression—an important step since 50 percent of women who have had depression will have another episode and 80 percent of women with PPD will have a second episode. Women who are at high risk can be monitored carefully for symptoms and women who are already showing signs of depression can be treated before their symptoms worsen. The existence of several screening tools, such as the Edinburgh Postnatal Depression Scale, can be a valuable aid in the early detection of PPD. Three categories of perinatal mood disorders
Baby blues Seventy to 80 percent of new moms may experience the baby blues, which are directly linked to the abrupt drop in hormones. Most cases peak on the fifth day after delivery and begin to abate, but a subset of women who have the baby blues may go on to develop PPD. PPD The disorder may be so debilitating, it can be difficult to bear for any length of time without treatment. A woman’s ability to function may be seriously impaired and symptoms may become so severe, they require hospitalization. Postpartum psychosis Postpartum psychosis is characterized by auditory hallucinations and delusions. Visual hallucinations may also occur. Other symptoms include insomnia, feeling agitated and angry. In most cases it severely impairs the affected woman’s ability to function. Treatment options Some women have had good experience with antidepressants and may wish to try that again. Others prefer psychotherapy because they are breastfeeding and don’t want to expose their infant to medication. Some wish to try both. There are few clinical trials involving antidepressant medication and pregnant and breastfeeding women because of the fear of birth defects and maternal/child transmission. Those that have been completed do show that the class of drugs known as serotonin reuptake inhibitors (SSRIs), which includes Prozac (Serafem® or fluoxetine), present little risk to infants and may provide significant benefits to women with PPD. In clinical trials a combination of medication and therapy provided the best result. All women, particularly those who have had previous episodes of depression, need to be aware of the appearance of symptoms and seek help immediately if they begin to experience any of them. No one should try to cope with serious depression on her own. Mental health professionals can offer several effective options for treating the disorder. Dr. Yonkers is an attending physician at Yale-New Haven Hospital and an associate professor of psychiatry at the Yale University School of Medicine. 
For the 12th year in a row, Yale-New Haven has been highly ranked by U.S. News & World Report for its programs in gynecology. |
