Name
POSTPARTUM DEPRESSION
DESCRIPTION
DETAIL
CAUSES Unknown. Perhaps multifactorial, including: biological-genetic predisposition in terms of brain chemistry, sudden drop in estrogen and progesterone levels at delivery, socioeconomic stress -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS β’ Baby blues β’ Postpartum psychosis β’ Postpartum anxiety/panic disorder β’ Postpartum obsessive compulsive disorder β’ Hypothyroidism β’ Sleep apneaLABORATORY β’ TSH β’ Estrogen and progesterone levels may be helpful (often low) SPECIAL TESTS β’ Polysomnograms for sleep apnea and/or daytime sleepiness. Sleep EEG to confirm short REM latency prognosticating a better response to antidepressants. β’ Psychological testing for personality/character disorders and provide clues for the best choice of nonpharmacological therapies IMAGING Head CT/MRI rarely needed DIAGNOSTIC PROCEDURES β’ Neuropsychological testing β’ Projective psychological testing β’ Beck, Hamilton and Zung depression inventories may provide information on the severity of the depression and suicidal risks
TYPENOTES
RISK FACTORS: Previous episodes of postpartum depression, Previous episodes of depression, History of depression during pregnancy, Family history of depression, Early childhood losses, Growing up with alcoholic dysfunctional parents RISK FACTORS β’ Previous episodes of postpartum depression β’ Previous episodes of depression β’ History of depression during pregnancy β’ Family history of depression β’ Early childhood losses β’ Growing up with alcoholic dysfunctional parents β’ Unwanted pregnancy β’ Presence of socioeconomic stress β’ Lack of social and family support system APPROPRIATE HEALTH CARE β’ Most patients respond to outpatient individual psychotherapy in combination with pharmacotherapy β’ Support/therapy groups helpful β’ Assess for homicidal and suicidal ideations β’ Visiting nurse services can provide direct observations of the mother regarding safety issues and bonding β’ Assess (consider psychiatrist consultation) patients for psychotic symptoms - if psychotic delusions or hallucinations present, immediate hospitalization needed. The psychotic mother should not be left alone with the baby. GENERAL MEASURES β’ Proper sleep and rest for the new mother are very important for stable mood. β’ Patient education and bibliotherapy for the patient and her family are helpful and valuable β’ ECT: Some patients who cannot tolerate the antidepressant medication, or who are actively engaged in suicidal self-destructive behaviors or who have a previous history of responding favorably to ECT should be seriously considered for treatment with ECT ACTIVITY Based on patients physical condition DIET β’ Good nutrition and hydration β’ The addition of a multivitamin with minerals may be helpful DRUG(S) OF CHOICE . SSRIs are effective and safe and are also effective for patients with depression and OCD symptoms. . Fluoxetine (Prozac) 20-80 mg/day (most activating of all SSRIs) . Sertraline (Zoloft) 50-200mg/day (sedating) . Paroxetine (Paxil) 20-60mg/day (sedating) . Citalopram (Celexa) 20-60mg/day . Escitalopram (Lexapro) 10-20 mg/day . Fluvoxamine (Luvox) 25-200mg/day (effective for postpartum depression associated with OCD) . Tricyclic antidepressants are effective and less expensive. Lethal in overdoses and have unfavorable side effects with less tolerance compared to the SSRIs. . Bupropion (Wellbutrin) 150-450mg/day in patients with depression plus psychomotor retardation, hypersomnia, low energy, general slowing and hyperphagia with weight gain. Bupropion does not cause weight gain nor sexual dysfunction. It is highly activating and safe in the SR (slow release) form. . Nefazodone (Serzone) 150-600mg/day with sedating effects but without causing sexual dysfunction nor weight gain nor REM sleep interruption. . Mirtazapine (Remeron) 15-45mg/day given at bedtime. Non-SSRI antidepressant helps with sleep restoration and in patients with weight loss. No sexual dysfunction side effects. . Venlafaxine (Effexor) is a dual action antidepressant that blocks the reuptake of serotonin in doses of up to 150mg/day and then blocks the reuptake of norepinephrine in doses of 150-450mg/day. The new XR (extended release) is given once daily and is also effective for the control of anxiety. . Duloxetine 30-60 mg/day ALTERNATIVE DRUGS β’ Lithium carbonate or valproic acid, may be added as a mood stabilizer and to augment antidepressant effect. However, both may be teratogenic in case of a new pregnancy. Buspirone (Buspar) may be added for the control of anxiety and for antidepressant augmentation. PATIENT MONITORING If psychotic symptoms present observe quality and safety of motherβs interaction with baby. Home observation and monitoring helpful. PREVENTION/AVOIDANCE β’ Routinely assess women in the third trimester for depression, to identify depression and begin treatment before or immediately after delivery. β’ Self-rating depression scales (e.g., Zung depression scale or the Beck depression scale) helpful POSSIBLE COMPLICATIONS β’ Self infl icted violence and suicide attempts β’ Psychotic delusions β’ Neglect of baby β’ Harm to the baby EXPECTED COURSE/PROGNOSIS Generally good. Improvement expected within a few months to a year. Some patients, particularly those with personality disorders, develop chronic depression requiring long term treatment.
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
TSH, SERUM E2 ( FEMALE ), SERUM PROGESTERONE ( MALE ), EEG