Title
Instructions: Listen to the podcast episode available below, and then submit your answers to the multiple choice questions. You will review the answers and the material covered during your next Continuity Clinic Session.
Perinatal Depression
A 23-year-old woman, gravida 1, para 1, underwent a spontaneous vaginal delivery 3 weeks ago. She has no history of depression or other psychiatric disorders. She has been having difficulty sleeping, even when her baby is asleep. She has minimal energy and feels as if she is failing as a mother. Her appetite is poor, and she says her mother has to force her to eat. At times, she has crying spells with acute onset. On mental status examination, she is oriented to person, place and time. The most likely diagnosis is
Show Explanation
• ACOG recommends screening for depression and anxiety at least once during the perinatal period using a validated tool like the EPDS or PHQ-9. Postpartum depression is diagnosed when a person has at least 5 of the following 9 symptoms that cause significant impairment in daily functioning within the first 4 weeks postpartum:
o Depressed mood
o Decreased interest in pleasurable activities (anhedonia)
o Decreased energy
o Changes in sleep pattern
o Changes in weight
o Decreased concentration or indecisiveness
o Feelings of guilt or worthlessness
o Psychomotor retardation or agitation
o Suicidal ideation
• Treatment of mild-to-moderate postpartum depression includes interpersonal psychotherapy and cognitive behavioral therapy. Pharmacologic therapy is recommended for moderate-to-severe postpartum depression, including SSRIs, which are also safe during lactation.
• Postpartum blues includes mild depressive symptoms, including irritability, tearfulness and decreased concentration that begins during the first 2-3 days after delivery and resolves within 10 days.
• Postpartum psychosis typically presents within 2 weeks postpartum and includes symptoms of hallucinations, delusions, and profound thought disorganization. The prevalence si 0.1-0.2% of new mothers. Bipolar disorder is characterized by alternating episodes of major depression and mania.
A 31-year-old patient, G2P1, is at 10 weeks of gestation. She has a history of depression and has never taken any medications. She has had no complications during this pregnancy. Today, she reports new onset of irritability, insomnia, and depressed mood but no suicidal ideation. She has lost 2 pounds since her last visit. Her Edinburgh Postnatal Depression Scale score is 14. The best treatment for her is
Show Explanation
• Perinatal depression includes minor and major depression occurring in pregnancy until 12 months postpartum. Patients should be screened at least once during pregnancy for depression. A positive screen on the EPDS is greater than 10.
• It is reasonable to start with a trial of psychotherapy, especially if the patient wishes to avoid pharmacotherapy. Psychotherapy is an appropriate choice for this patient, who may benefit from cognitive behavioral therapy or interpersonal psychotherapy.
• If psychotherapy fails or is not available, medical treatments with antidepressants can be beneficial. SSRIs are the most commonly prescribed medications for depression, and include sertraline, fluoxetine, citalopram, and paroxetine. There have been some studies linking paroxetine to fetal cardiac anomalies. SSRI use near the end of pregnancy is associated with transient neonatal complications including jitteriness, mild respiratory distress, and transient tachypnea.
• If the patient is actively suicidal or psychotic, they should be evaluated by a psychiatrist immediately to initiate aggressive therapy and optimize treatment quickly.
• Electroconvulsive therapy is a safe option for patients with severe or life-threatening depression after other treatments have failed.
A 33-year-old nulligravid woman presents for pre-pregnancy counseling. She has depression that is well-controlled on paroxetine. You counsel her that the birth defect with which paroxetine has been associated is
Show Explanation
• Up to 70% of pregnant women report depressive symptoms, including depressed mood, anhedonia, changes in sleep, appetite, and weight, decreased energy, feelings of guilt or worthlessness, psychomotor retardation or agitation, and suicidal ideation.
• Untreated or undertreated maternal depression is associated with serious risks, including suicide and homicide. Women who discontinue their antidepressants are 5 more times likely to relapse than those who continue an antidepressant regiment during pregnancy.
· •Studies have shown an up to twofold increased risk of cardiac malformations in fetuses of women who used paroxetine. This medication has not been shown to increase the risk of any of the other malformations listed. Paroxetine should be avoided during pregnancy if possible, but discussion of use should include information regarding the balance of potential risks of fetal medication exposure versus the risk of relapse of depression. Abrupt discontinuation of paroxetine may cause maternal withdrawal symptoms, so if the decision is made to discontinue paroxetine if should be done according to the prescribing information.
· Antidepressant use has been associated with transient neonatal complications, including jitteriness, transient tachypnea of the newborn, mild respiratory distress, and NICU admission. Some recent studies have suggested that SSRIs may be associated with persistent pulmonary hypertension of the newborn, although the absolute risk of this complication remains low.