A 25-year-old woman comes to the office accompanied by her husband. She is 1 week postpartum and has been sleeping poorly and crying for no reason. The patient's pregnancy and vaginal delivery were uncomplicated. She has some anxiety about being a new mother but says that her mother is helping and the baby is doing well. The patient says, "I was thrilled after giving birth and can't understand why I now feel so tense and unhappy." Her husband adds that his wife is uncharacteristically irritable and they fight frequently. Last night she yelled at him for failing to help with the baby's nighttime feeding and later felt remorseful for her behavior. The patient has a history of a major depressive episode that began after she moved away from home for college but responded well to psychotherapy and fluoxetine. She has no other medical problems, takes no medication and is not breastfeeding. Mental status examination shows a visibly tired woman with tense affect. She has no suicidal or homicidal ideation. Which of the following is the most appropriate intervention?
Postpartum blues, depression & psychosis | |||
Postpartum | Postpartum depression | Postpartum psychosis | |
Prevalence | 40%-80% | 8%-15% | 0.1%-0.2% |
Onset | 2-3 days (resolves within 14 days) | Typically within 4-6 weeks (can be up to 1 year) | Variable: days to weeks |
Symptoms | Mild depression, tearfulness, irritability | ≥2 weeks of moderate to severe depression, sleep or appetite disturbance, low energy, psychomotor changes, guilt, concentration difficulty, | Delusions, hallucinations, thought disorganization, |
Management | Reassurance & monitoring | Antidepressants, psychotherapy | Antipsychotics, antidepressants, mood stabilizers; hospitalization (do not leave mother alone with infant due to risk of infanticide) |
This patient's mood disturbance is most consistent with postpartum blues, a normal, self-limited condition that occurs within a few days postpartum. Symptoms occur in 40%-80% of women and include mild depressive symptoms such as tearfulness, irritability, dysphoria, anxiety, insomnia, and impaired concentration. These symptoms typically peak at 5 days and resolve within 2 weeks. The most appropriate response is to reassure the patient that her symptoms should improve shortly and instruct her to call if they do not remit spontaneously. Helping the mother obtain adequate rest and assisting with child care if needed are also beneficial.
Although the majority of women with postpartum blues will recover spontaneously, these patients are at increased risk of developing postpartum depression. They should be monitored for symptoms that may indicate postpartum depression, including persistence beyond 2 weeks or the development of suicidal ideation.
(Choices A, B, C, D, E, and G) Because postpartum blues is typically self-limiting, it is premature to recommend psychiatric consultation or begin treatment with psychotherapy (eg, interpersonal psychotherapy, cognitive behavioral therapy) or an antidepressant. Psychoeducation would be helpful at this stage. Treatment can be considered if symptoms worsen or persist beyond 2 weeks. Patients with postpartum depression can be treated with psychotherapy and/or antidepressants. Sertraline is a preferred antidepressant in women who are breastfeeding as levels in breast milk are generally low or undetectable.
Educational objective:
Postpartum blues is a self-limited condition that presents with mild depressive symptoms such as tearfulness, irritability, dysphoria, anxiety, insomnia, and impaired concentration. The condition begins several days postpartum and typically resolves within 2 weeks. Women with more severe depressive symptoms lasting for ≥2 weeks should be evaluated for postpartum depression.