Recognizing and Screening for Postpartum Depression in Mothers of NICU Infants

Adv Neonatal Care. 2003;3(1)

The Spectrum of Postpartum Mood Disorders

The 3 most well-known postpartum mood disorders are as follows:

Maternity blues
PPD
Postpartum psychosis

Recent studies link additional mood and anxiety disorders to childbirth.^[9,10,11,12] These disorders include the following:

Postpartum panic disorder^[9]
Postpartum obsessive compulsive disorder^[10]
Posttraumatic stress disorder (PTSD)^[11,12]

Each of these 6 postpartum psychiatric illnesses is composed of its own unique blend of symptoms, as well as its own damaging potential for mothers and their infants.

Maternity blues is a transitory phenomenon, experienced by 50% to 80% of new mothers, that occurs within the first few days after delivery. It lasts only a short time, sometimes only for a few hours or a few days. Common symptoms include tearfulness, mood swings, and fatigue. Symptoms that persist beyond 2 weeks are more serious and inconsistent with simple maternity blues (Fig 1).

(Enlarge Image)

It is common to experience maternity blues that may last for a few hours or days after birth. Postpartum depression should be considered when symptoms of depression last longer than 2 weeks.

PPD is a mood disorder that occurs in 13% of new mothers.^[13] It is similar to a major depressive episode as defined by the Diagnostic and Statistical Manual of Mental Disorders.^[14] PPD is diagnosed when a patient reports 2 weeks of dysphoric mood or lack of interest or pleasure in usual activities, in addition to at least 4 of the following 9 symptoms: sleep disturbance, guilt, fatigue, impaired concentration, appetite disturbance, psychomotor activation or retardation, low self-esteem, feelings of hopelessness and worthlessness, and suicidal ideation.^[14] A formal diagnosis is made by a trained mental health clinician based on the results of a diagnostic interview such as the Structured Clinical Interview for DSM-IV Axis I Disorders.

Postpartum psychosis is a rare, extremely serious mental illness that occurs in 1 to 2 per 1,000 deliveries. It usually presents in the first 2 to 3 weeks after delivery and requires urgent treatment. Clinical characteristics can include delusions; hallucinations; agitation; inability to sleep; and bizarre, irrational behavior.^[15] Pre-existing bipolar disorder increases the vulnerability of women to episodes of postpartum psychosis.^[16]

Postpartum panic disorder is a syndrome characterized by recurrent, unexpected episodes of at least 4 symptoms. These symptoms have an abrupt onset and peak within 10 minutes. Symptoms can include shortness of breath, heart palpitations, tremulousness, light-headedness, paresthesias, hot flushes or chills, nausea, diaphoresis, chest tightness, choking sensation, and cognitive symptoms of derealization and depersonalization, losing control or going crazy, impending doom, or fear of dying.^[14] In postpartum obsessive-compulsive disorder, women experience repetitive, intrusive thoughts of harming their infants, fear of being left alone with their babies, and hypervigilant protectiveness of their infants.^[10]

PTSD after childbirth is an underrecognized phenomenon that may occur in 3% to 5.6%^[11,12] of women secondary to birth trauma. The exposure to a traumatic birth-related event leads to characteristic symptoms such as persistent re-experiencing of the event, avoidance of reminders of the stressor, numbing of responsiveness, and symptoms of increased arousal.^[14] Examples of reported stressors precipitating PTSD after childbirth have ranged from a perception of inadequate care during labor and delivery to emergency cesarean deliveries.

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Cite this: Recognizing and Screening for Postpartum Depression in Mothers of NICU Infants - Medscape - Feb 01, 2003.

Introduction
The Spectrum of Postpartum Mood Disorders
Predictors of PPD
The Experience of PPD
PPD and Mothers of Multiples and Preterm Infants
The Effect of PPD on Infants and Children
Implications for Caregivers in the NICU
Conclusion
References
Sidebar: Understanding the Reliability and Validity of the PDSS

Table 1. Significant predictors for PPD
Prenatal depression Low self-esteem Childcare stress Prenatal anxiety Life stress Low social support Poor marital relationship History of previous depression Difficult infant temperament Maternity blues Single marital status Unplanned/unwanted pregnancy Low socioeconomic status

Table 2. Interpretation of the PDSS total score
PDSS Total Score Range	Interpretation	Implications for Practice
35-59	Normal adjustment	Women who score in this range generally do not need to be referred for psychiatric evaluation, unless there is a strong indication of significant depression or other psychopathology from another source of information. Provide basic information about PPD and postpartum adjustment, perhaps in the context of explaining the purpose of PDSS. It is also advisable to readminister the PDSS every 3 months during the first 12 months after delivery to provide continued screening for PPD.
60-79	Significant symptoms of PPD	Some, though not all, of the women scoring in this range are in need of formal psychiatric evaluation. In deciding whether to refer a woman in this range for further evaluation consider the following: The woman's medical and psychiatric history. Feedback from significant others. Assess for evidence that the woman poses a danger to herself or to others, and refer immediately for psychiatric evaluation. Discuss your assessment with the multidisciplinary team. Good clinical judgment will dictate whether a psychiatric referral is appropriate for a woman in this range. Other useful interventions that may reduce the risk for exacerbation of depression include the following: Education and anticipatory guidance regarding PPD. Review treatments for depression (eg, psychotherapy, medication). Provide practical advice on what the woman should do if she feels her mood worsen (eg, how to access specialists in the treatment of PPD). Provide a list of local new-mother and PPD support groups. It is advisable to readminister the PDSS to the woman at all of her subsequent contacts with the health care system during the first 12 months after delivery.
80-175	Positive screen for major PPD	Although this is not equivalent to a DSM-IV diagnosis of Major Depressive Disorder With Postpartum Onset, it does indicate a high probability that the woman has this disorder. Refer to the mental health team for further assessment and treatment as soon as possible. Refer immediately to the emergency psychiatric services if there is indication of danger to self (eg, elevation of the PDSS Suicidal Thoughts scale) or to others. Note: Whenever the PDSS Total score is elevated above the range of normal adjustment, it is useful to examine the scores for the symptom content scales to characterize the pattern of symptoms for an individual respondent.

Table 3. Web resource list for postpartum depression
Web Site	Internet Address	Description of Contents
Depression After Delivery (D.A.D.)	www.depressionafterdelivery.com Depression After Delivery, Inc. 91 East Somerset Street Raritan, NJ 08869 1-800-944-4773 (4PPD) (Information Request Line)	Depression After Delivery, Inc. (D.A.D.) is a national nonprofit organization founded in 1985 by Nancy Berchtold after experiencing her own postpartum complications. It was formed to provide support for women with PPD, postpartum psychosis, and the baby blues. The organizations' focus includes education, information, and referral for women and families coping with mental health issues associated with child bearing, both during pregnancy, postpartum, and beyond. D.A.D. provides information on pregnancy and postpartum disorders, a professional referral list, a list of volunteer telephone contacts, and support groups.
PSI: Postpartum Support International	www.postpartum.net Postpartum Support, International 927 North Kellogg Avenue Santa Barbara, CA 93111 USA (805) 967-7636 jhonikman@earthlink.net	The purpose of this non-profit organization is to increase awareness among public and professional communities about the emotional changes that women often experience during pregnancy and after the birth of a baby. They provide current information on the diagnosis and treatment of postpartum mood and anxiety disorders; advocate research into etiology, diagnosis, and treatment of postpartum mood and anxiety disorders; provide education about mental health issues of childbearing; address legal and insurance coverage issues; encourage collaboration with related organizations; encourage health care professional participation in PSI; encourage the formation of new groups and strengthen existing support groups; and sponsor an annual PSI conference to review progress in achieving these objectives.
Symptoms of Depression.com	www.symptoms-of-depression.com	A comprehensive Web site dedicated to the topic of depression including postpartum depression.
The Online PPD Support Group	www.ppdsupportpage.com	The Online PPD Support Group offers information, support, and assistance to those dealing with postpartum mood disorders, their families, friends, physicians, and counselors

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Recognizing and Screening for Postpartum Depression in Mothers of NICU Infants

The Spectrum of Postpartum Mood Disorders

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Sidebar: Understanding the Reliability and Validity of the PDSS

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