A 28-year-old woman, gravida 1 para 1, comes for a routine 4-week postpartum visit following an uncomplicated vaginal delivery. The patient describes some mild vaginal soreness and breast tenderness but has no other physical problems. She says, "The baby is adorable, but I worry about being a good mother." She tearfully describes feeling exhausted and unable to return to sleep after getting up in the middle of the night to feed the baby. She says, "The baby cries all the time and nothing I do helps. I tried to breastfeed, but I gave it up because she was fussy and I was afraid she wasn't getting enough to eat. My husband tries to be supportive and has offered to help with nighttime feedings, but I am up at night anyway because I can't sleep." The patient has little time to care for herself and has been eating poorly. She feels increasingly depressed and has little energy. The patient says, "Everyone expects me to be happy, but it has been so hard. I don't deserve to be a mother." The patient has no psychiatric history and no thoughts of hurting herself or the baby. Physical examination is normal. Routine laboratory tests, including hemoglobin and TSH levels, are within normal range. Which of the following is the most appropriate next step in management of this patient?
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) |
All women should be routinely assessed for depression at postpartum visits. This patient is showing signs and symptoms of postpartum depression (depressed mood, insomnia, appetite disturbance, low energy, and feelings of worthlessness) at her 4-week checkup. Postpartum depression should be distinguished from postpartum blues, a self-limited condition with milder symptoms that resolves within 2 weeks postpartum. When depressive symptoms persist beyond 2 weeks and cause functional impairment, treatment is indicated. Options include psychotherapy, pharmacotherapy, or both.
Among antidepressants, selective serotonin reuptake inhibitors are commonly used as first-line therapy in treatment-naïve patients as they have demonstrated efficacy and tolerability in postpartum depression. In breastfeeding patients, sertraline is preferred as levels in infants are usually undetectable.
(Choice A) Postpartum blues is a normal, self-limited condition characterized by mild depressive symptoms such as tearfulness, irritability, dysphoria, anxiety, insomnia, and impaired concentration. Symptoms typically peak at day 5 and resolve by 2 weeks. This patient's symptoms are more severe and persistent and require treatment.
(Choices B and E) Although a new mother support group and parenting skills training would be helpful adjuncts, they are not sufficient to address this patient's untreated depression.
(Choice C) Psychiatric hospitalization would be indicated if the patient posed a risk to herself or the baby and/or was unable to adhere to outpatient treatment. Assessment of postpartum depression should always include questions regarding thoughts of suicide or harming the baby.
Educational objective:
All women should be assessed for depression at their postpartum follow-up visits. Treatment options for postpartum depression include psychotherapy and/or pharmacotherapy. Selective serotonin reuptake inhibitors are used as first-line therapy.