The pediatrician's role in recognizing and intervening in postpartum depression
Section snippets
Defining postpartum mood disorders
Postpartum mood disorders are generally divided into three categories: postpartum blues, postpartum depression, and postpartum psychosis [12]. Postpartum blues, commonly called “maternal blues” or “baby blues,” are the most common and least serious of the three. They occur in up to 85% of women in the first 3 to 7 days postpartum [12] and are characterized by mood swings, tearfulness, generalized anxiety, and irritability [12], [15]. This phenomenon is considered normal, and referral or
Pathogenesis
Although there are many theories, the exact pathogenesis of PPD is unknown. The immediate postpartum period has hormonal fluctuations, abrupt lifestyle changes, and significant other physical stressors for the mother, such as fatigue, postpartum pain, and the pain and stress sometimes associated with breastfeeding. All of these stressors are proposed mechanisms; the true pathogenesis is surely multifactorial. Recent biologic theories have centered on the rapid decrease in progesterone,
Identifying women at risk
Because the prevalence of PPD is so high, it is crucial to screen all postpartum women for symptoms. Some populations are at higher risk, however. Many risk factors have been identified for PPD, and studies are ongoing. Although not all studies agree on all risk factors, the ones most commonly reported and most strongly associated with PPD are a history of depression preceding or during the pregnancy or history of an episode of PPD after previous pregnancies. Some researchers have estimated
Detection: barriers and methods
In a study of 508 primary care pediatricians who completed surveys, only 57% believed that it was their responsibility to recognize maternal PPD [6]. When PPD was suspected, additional assessment of any kind was conducted by only 48% of those pediatricians who routinely monitored for PPD [6]. Multiple studies demonstrate the underdiagnosis of PPD. Pediatricians' perceptions of major barriers believed to limit diagnosis or management of PPD have included insufficient time for adequate history
Impact on the mother and child
When untreated, PPD results in poor outcomes for mother and child. Recurrence is common. Women with a previous episode of PPD are at a 25% to 50% higher risk of experiencing episodes during subsequent pregnancies [12], [35], [36]. The neonatal period is an important time for the development of the maternal-infant bond, and neonates and young infants are incredibly sensitive to emotions of their caregivers. They react to the maternal affective state as young as 3 months [37] with well-organized
Treatment
Although it is not the role of the pediatrician to diagnose and treat PPD formally, it is important to be aware of the various treatments available. First, it helps the pediatrician to explain to the mother why referral to her own primary doctor or other health care professional could prove helpful. Second, pediatricians may be consulted regarding the safety of breastfeeding and psychotropic medications (this issue is addressed more fully in the next section). Finally, because one of the
Drug therapy during lactation
Although therapy with SSRIs or other antidepressants tends to be viewed by most practitioners as relatively benign for the mother, there is one group of women for whom the decision to start pharmacotherapy is less clear: lactating mothers. Although several retrospective and case report studies have been published, no prospective randomized trials or large cohort studies have been conducted regarding the effects of antidepressants on infants of breastfeeding mothers [59]. There are no clear
Summary: the pediatrician's role in detection and intervention
Pediatricians are responsible for providing comprehensive well-child care. Standard postpartum care for the mother usually consists of a single follow-up visit with her doctor 6 weeks after delivery. Standard well-child care includes (at times) a visit within 48 hours of discharge, a 1- or 2-week visit, then visits at 2, 4, and 6 months of age with the child's doctor. Consequently, the opportunities for detection are much greater for the pediatrician than the mother's obstetrician or family
Summary
Increasing evidence is being published in pediatric literature to encourage pediatricians to include screening and intervention for PPD in standard newborn and infant care. Pediatricians have the most frequent exposure to mothers and infants in the most high-risk time period and they have a vested interest in the well-being of the child and mother. Because the time required to achieve basic screening and referral services is minimal, there is clearly enough evidence that PPD screening and
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