A 24-year-old woman calls her obstetrician after giving birth to a healthy boy 5 days earlier. She reports feeling depressed and irritable: "I thought I would be thrilled to have a baby, but then I felt really disappointed it was not a girl and find myself crying constantly." The patient gets help from her sister during the day but is exhausted due to getting up at night to feed the baby. She says, "My sister is so helpful, but I can't help snapping at her for no reason. I get so worried that I won't be a decent mother." The patient has no medical or psychiatric history, and the pregnancy and delivery were unremarkable. She has no suicidal ideation or thoughts of harming the baby. In addition to providing support, which of the following is the most appropriate response to the patient?
Postpartum blues, depression & psychosis | |||
Postpartum blues | 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, suicidal ideation | Delusions, hallucinations, thought disorganization, bizarre behavior |
Management | Reassurance & monitoring | Antidepressants, psychotherapy | Antipsychotics, antidepressants, mood stabilizers; hospitalization (do not leave mother alone with infant due to risk of infanticide) |
This patient most likely has postpartum blues, a normal, self-limiting condition that occurs within a few days postpartum. Symptoms include mild depressive symptoms (eg, sadness, insomnia, tearfulness, irritability, anxiety, impaired concentration). These symptoms typically peak at 5 days and resolve within 14 days.
The most appropriate response would be to reassure the patient that postpartum mood changes are common and to monitor her closely with instructions to call back if she does not start to improve. If symptoms do not remit spontaneously by day 14, a follow-up should be scheduled. Waiting until the 6-week postpartum check would be inadequate as women with postpartum blues are at increased risk of developing postpartum depression, which typically presents within 4-6 weeks of delivery (Choice C). The much rarer postpartum psychosis can present with delusions and command hallucinations to kill the infant and represents a psychiatric emergency.
(Choice A) There is no evidence that the patient is unable to care for the infant, and this statement is likely to be perceived as critical. Asking the patient whether she has any concerns about caring for her infant or needs extra support would be more appropriate.
(Choices B and E) Because this patient is calling on day 5 (often the peak of postpartum blues), it would be premature to refer her to a counselor or to diagnose or treat postpartum depression. Postpartum blues is self-limiting and resolves without treatment.
Educational objective:
Postpartum mood disturbances include postpartum blues, postpartum depression, and, rarely, postpartum psychosis. The most common disturbance, postpartum blues, is a benign, self-limited condition that begins several days postpartum and resolves within 14 days without intervention.