para>Obtain psychiatric consultation for patients with psychotic symptoms. If delusions or hallucinations are present, strongly consider immediate hospitalization. The psychotic mother should not be left alone with the baby.
Admission Criteria/Initial Stabilization
Presence of suicidal or homicidal ideation and/or psychotic symptoms and/or thoughts of harming baby and/or inability to care for self or infant, severe weight loss
Discharge Criteria
- Absence of suicidal or homicidal ideation and/or psychotic symptoms and/or thoughts of harming the baby
- Mother must be able to care for self and infant.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Collaborative care approach, including primary care visits and case manager follow-ups
- Consultation with the infant's doctor, particularly if the mother is breastfeeding while taking psychotropic medications
DIET
- Good nutrition and hydration, especially when breastfeeding
- Mixed evidence to support the addition of multivitamin with minerals and omega-3 fatty acids
PATIENT EDUCATION
- This Isn't What I Expected: Overcoming Postpartum Depression, by Karen R. Kleinman and Valerie Davis Raskin
- Down Came the Rain: My Journey Through Postpartum Depression, by Brooke Shields, 2005
- Behind the Smile: My Journey Out of Postpartum Depression, by Marie Osmond, Marcia Wilkie, and Judith Moore, 2001
- Web resources
- Postpartum Support International: http://www.postpartum.net/
- La Leche League: http://www.llli.org/
- http://toxnet.nlm.nih.gov/
- http://www.mededppd.org/
- http://www.womensmentalhealth.org/
- http://www.motherrisk.org/
- http://www.step-ppd.com/
PROGNOSIS
- Treatment of maternal depression to remission has been shown to have a positive impact on children's mental health.
- Some patients, particularly those with undertreated or undiagnosed depression, may develop chronic depression requiring long-term treatment.
- Untreated maternal depression is linked to impaired mother-infant bonding and cognitive and language development delay in infants and children (8).
- Postpartum psychosis is associated with tragic outcomes such as maternal suicide and infanticide.
COMPLICATIONS
- Suicide
- Self-injurious behavior
- Psychosis
- Neglect of baby
- Harm to the baby
REFERENCES
11 Stuart-Parrigon K, Stuart S. Perinatal depression: an update and overview. Curr Psychiatry Rep. 2014;16(9):468.22 Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490-498.33 Bobo WV, Yawn PB. Concise review for physicians and other clinicians: postpartum depression. Mayo Clin Proc. 2014;89(6):835-844.44 Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1):1071-1083.55 Cerulli C, Talbot NL, Tang W, et al. Co-occurring intimate partner violence and mental health diagnoses in perinatal women. J Womens Health (Larchmt). 2011;20(12):1797-1803.66 Nicholson WK, Robinson KA, Smallridge RC, et al. Prevalence of postpartum thyroid dysfunction: a quantitative review. Thyroid. 2006;16(6):573-582.77 Pearlstein T, Howard M, Salisbury A, et al. Postpartum depression. Am J Obstet Gynecol. 2009;200(4):357-364.88 Fitelson E, Kim S, Baker AS, et al. Treatment of postpartum depression: clinical, psychological and pharmacological options. Int J Womens Health. 2010;3:1-14.
ADDITIONAL READING
- Edinburgh Postnatal Depression Scale. http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.
- Gjerdingen D, Katon W, Rich DE. Stepped care treatment of postpartum depression: a primary care-based management model. Womens Health Issues. 2008;18(1):44-52.
- Harrington AR, Greene-Harrington CC. Healthy Start screens for depression among urban pregnant, postpartum and interconceptional women. J Natl Med Assoc. 2007;99(3):226-231.
- Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician. 2010;82(8):926-933.
- Howard LM, Boath E, Henshaw C. Antidepressant prevention of postnatal depression. PLoS Med. 2006;3(10):e389.
- Kendall-Tackett K. A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Int Breastfeed J. 2007;2:6.
- Musters C, McDonald E, Jones I. Management of postnatal depression. BMJ. 2008;337:a736.
- Ng RC, Hirata CK, Yeung W, et al. Pharmacologic treatment for postpartum depression: a systematic review. Pharmacotherapy. 2010;30(9):928-941.
- Sit DK, Wisner KL. Identification of postpartum depression. Clin Obstet Gynecol. 2009;52(3):456-468.
- Tammentie T, Tarkka MT, Astedt-Kurki P, et al. Family dynamics and postnatal depression. J Psychiatr Ment Health Nurs. 2004;11(2):141-149.
CODES
ICD10
- F53 Puerperal psychosis
- O90.6 Postpartum mood disturbance
ICD9
- 648.44 Mental disorders of mother, postpartum condition or complication
- 648.42 Mental disorders of mother, delivered, with mention of postpartum complication
SNOMED
- 58703003 postpartum depression (disorder)
- 279225001 Maternity blues
CLINICAL PEARLS
- PPD is a common, debilitating medical condition that impairs a mother's ability to function and interact with her infant and family.
- Universal screening for depression is recommended during the 1st and 3rd trimester and at regular intervals during the postpartum period.
- Early diagnosis and treatment are vital, as untreated PPD can lead to developmental difficulties for the infant and prolonged disability and suffering for the mother.
- Breastfeeding is recommended for maternal and child health. Several medication options for treating depression in mothers are safe for breastfeeding infants.
- Treatment with antidepressants should be individualized for breastfeeding mothers (4)[B].