Recognizing and Managing Postpartum Depression

An Expert Interview With Barbara Yawn, MD, MSc, FAAFP

Steven Fox

September 16, 2011

September 16, 2011 (Orlando, Florida) — Editor's note: Postpartum depression is common and often not only affects the mother but has serious consequences for her spouse and the child as well.

At a special session held here at the American Academy of Family Physicians Scientific Assembly, Barbara Yawn, MD, MSc, FAAFP, gave attendees practical advice on how to recognize and manage postpartum depression. Central to her message: family physicians can and should treat postpartum depression because many women referred to specialists often fail to keep their appointments and go untreated.

Dr. Yawn is director of research, Olmsted Medical Center, and adjunct professor, family and community health, University of Minnesota in Rochester.

In an interview with Medscape Medical News, Dr. Yawn summarized some of the highlights of her presentation. Excerpts of that interview follow.

Medscape: Why is postpartum depression, or PPD, an important issue for family care physicians to be concerned about?

Dr. Yawn: One out of every 6 to 8 women will have depressive symptoms in the 12 months after they deliver a baby. Many will have a full blown major depressive disorder, which, if unresolved, is associated with delayed social and cognitive development in their infants. And those sorts of problems can persist in the child through age 12. The depression also doubles the chances of divorce or partnership dissolution, leaving the woman to cope with a major burden of symptoms on her own.

To date, only 50% of postpartum depression cases are recognized, and only about 20% are treated.

Whether family physicians provide maternity care or not, they do see these women and often their infants during the first year of life. This is the time to assess for depression and begin the treatment process. Postpartum depression is not just a problem for a few weeks for a few women, it lasts months and affects babies, moms, and families.

You may also see the undiagnosed women for a variety of nonspecific and difficult-to-diagnose symptoms. You need to include postpartum depression in your differential diagnosis or you may go on being frustrated by a woman in distress who you don't know how to help. 

Medscape: When women with symptoms of PPD present to family care physicians, they're often immediately referred to a specialist for care. But from your presentation I gather that you don't think that's always necessary. What's the rationale behind that view?

Dr. Yawn: Several studies have demonstrated that women with postpartum depression do not want to be referred for basic depression management. Furthermore, they often do not go to those referral visits and so their symptoms remain untreated. With some additional basic training, family physicians can manage major depression and save the referrals for women who do not improve or have complex mental health issues like bipolar disorder or schizophrenia or postpartum psychosis. 

Medscape: You talked about some of the screening and diagnostic tools used for postpartum depression. Would you summarize those for us, and describe what information those tools can provide?

Dr. Yawn: I talked about 2 tests: the Edinburgh Postnatal Depression Scale, EPDS for short, and the Patient Health Questionnaire-9, or PHQ-9. Unfortunately, neither of these tests is often used to screen postpartum women for signs of depression, but both are useful.

Both screening tools ask about the common symptoms of PPD, including mood changes, lack of energy, sleep disturbances due to mood, lack of pleasure, and suicidal ideation.

The EPDS is specifically designed for the postpartum period and may be the better choice. It also asks about anxiety, which may be very important in PPD.

The PHQ-9 is designed to help primary care physicians screen, diagnose, and assess severity of depression as well as monitor response to therapy. It can be used in patients of all ages.

Medscape: You also talked about key questions family care physicians can ask new mothers to establish a dialogue about postpartum depression. Would you give us some examples?

Dr. Yawn: You can follow up on the depression screening questions by asking some additional questions: "How well you are sleeping? Are there problems due to having to get up with the baby for feeding or other reasons? Are you finding any time for yourself? Do you have support at home?"

If the patient's screening score is high, you might ask: "The screening questions suggest you may be having some problems with sad mood or even depression, what do you think?" or "Many women who have screening scores like yours have postpartum depression. Does that describe you?"

"What experience do you have with depression in yourself or family members or friends? I think that depression is a medical condition like diabetes or high blood pressure. What's your impression of depression?"

Medscape: Okay, so once a diagnosis of PPD has been established, what's the best way to treat it?

Dr. Yawn: Talk to the patient about her preference, stating that you believe she needs therapy to improve these symptoms.

Remember that both cognitive-behavioral therapy — not just "talk" therapy — and medication work equally well. Medications usually begin working a bit more rapidly.

You can use antidepressants in breast feeding. Just use a good reference to make sure you know which ones have the least risk.

Begin the medications slowly in the first week to minimize side effects.

Increase over 1 to 3 weeks to therapeutic doses.

Have the patient schedule a follow-up visit (and another PHQ-9) in 4 weeks to see if her score drops by 3 to 5 points. If it does, that suggests the treatment is working. If it doesn't drop, increase to maximal doses and recheck in 4 more weeks.

If you make no progress in 6 to 8 weeks, change or add medications or add therapy to medications or consider referral.

Medscape: So what bullet points would you like to leave with your audience?

Dr. Yawn: Family physicians should:

  1. Screen for depression.

  2. Have a way to evaluate women with high scores. You can do this by making sure you have ruled out other causes of the symptoms like hypothyroidism, substance abuse, and other major mental health disorders.

  3. Learn how to comfortably use 2 to 4 antidepressants and use them properly, assessing adherence early and going to therapeutic doses and even to maximal doses when necessary.

  4. Have a simple plan to deal with suicidal ideation so that everyone is comfortable. You won't need it often, but when you do it is very nice to have handy.

  5. Follow your patients. Depression is a chronic condition and like diabetes requires regular follow-up visits. Use the PHQ-9 to assess response to therapy just as you use hemoglobin A1c to assess diabetes therapy.

  6. Depression is common and should initially be treated in primary care like other common conditions. You can do it effectively and with greater comfort for the patients than referring all of them to appointments they are unlikely to attend.

Dr. Yawn has disclosed no relevant financial relationships.

American Academy of Family Physicians Scientific Assembly; September 14-17, 2011.

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