Differentiation and clinical implications of postpartum depression and postpartum psychosis

P R I N C I P L E S & P R A C T I C E Differentiation and Clinical Implicationsof Postpartum Depression andPostpartum PsychosisShelley Doucet, Cindy-Lee Dennis, Nicole Letourneau, and Emma Robertson Blackmore Postpartum depression and postpartum psychosis are serious mood disorders encountered by nurses working in a University of NewBrunswick, Department of variety of settings. Postpartum depression refers to a nonpsychotic depressive episode, while postpartum psychosis refers to a manic or affective psychotic episode linked temporally with childbirth. The nursing profession plays a crucial role in the early identification and treatment of these postpartum mood disorders. This article explains the classi- fication, clinical presentation, epidemiology, management, and long-term outcomes of postpartum depression and JOGNN, 38, 269-279; 2009. DOI: 10.1111/j.1552-6909.2009.01019.x perinatalpostpartum depressionpostpartum psychosis Shelley Doucet, MScN,RN, is a doctoral candidate Mood disorders in the postpartum period are these disorders. The purpose of this paper is to serious mental health conditions that nega- provide a clear understanding of the classi¢cation, tively a¡ect many women from diverse cultures.
clinical presentation, epidemiology, management, Postpartum mood disorders are commonly classi- and long-term outcomes of PPD and PP.
¢ed into three categories: postpartum blues, Brunswick, Department ofNursing, NB, Canada.
postpartum depression (PPD), and postpartum psychosis (PP). However, the terms PPD and PP are often used interchangeably. Confusion regard- RN, is an associateprofessor in the Faculty of ing the correct use of PPD and PP can have The classi¢cation of postpartum mood disorders numerous clinical and research implications in- has been a source of contention for many years.
cluding inappropriate diagnoses and treatment The argument concerns whether these disorders regimes. If left untreated, both disorders can result should be classi¢ed as distinct entities or be con- Health at the University ofToronto, Toronto, ON, in negative consequences including the risk of sidered as part of existing conditions (Brockington, recurrent psychiatric illness (Cooper & Murray, 1995; 1996). Most experts agree that PPD and PP are not Robertson, Jones, Haque, Holder, & Craddock, distinct diagnostic entities. The current psychiatric 2005), marital dysfunction (Meighan, Davis, Tho- classi¢cation systems, the Diagnostic and Statisti- RN, is a professor in theFaculty of Nursing and mas, & Droppleman, 1999; Robertson & Lyons, cal Manual of Mental Disorders, 4th ed., Text 2003), suicide (Appleby, Mortensen, & Faragher, Revision (DSM-IV-TR) (American Psychiatric Asso- 1998), and infanticide (Spinelli, 2004). Research on at the University of NewBrunswick, NB, Canada.
PPD has shown that the infant is at risk for behav- Classi¢cation of Diseases, Tenth Revision (ICD-10) ioral problems (Beck, 1999), delayed cognitive or (World Health Organization, 1992) re£ect this view psychosocial development (Beck, 1998; Grace, and use a postpartum onset speci¢er within cate- Evindar, & Stewart, 2003), and impaired mother- gories. The DSM-IV-TR de¢nes postpartum onset assistant professor in theDepartment of Psychiatry, infant bonding (Beck, 1995). Most new mothers to be within 4 weeks of delivery and can be used interact with nurses in the postpartum period. Ac- for various mood disorders, brief psychotic disor- cordingly, it is important that nurses have a good der, or psychotic disorder not otherwise speci¢ed.
understanding of PPD and PP in order to provide The ICD-10 de¢nes postpartum onset to be within the best possible care for women experiencing 6 weeks of delivery and can be used for mental & 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses P R I N C I P L E S & P R A C T I C E Postpartum Depression and Postpartum Psychosis psychosis, and brief psychotic disorder. Studies Nurses who interact with mothers in the postpartum period show that most cases of PP represent a variant of must have a good understanding of postpartum bipolar disorder triggered by childbirth (Brocking- depression and postpartum psychosis.
ton et al., 1981; Jones & Craddock, 2001; Kendell, Chalmers, & Platz, 1987). A presentation of PP can be predominately depressive and di¡ers from PPD disorders that do not meet the criteria for mental and behavioral disorders classi¢ed elsewhere.
perplexity, or manic or mixed features are present schizophrenia are rare with a relative risk of less Research consistently demonstrates that PPD does than one in the postpartum period; this compares not di¡er in symptomatology from major depression with a 22-fold risk of a¡ective psychosis (Terp, Eng- (Brockington, 1996); hence, in most cases, PPD is holm, Moller, & Mortensen, 1999). Schizophrenia diagnosed as a major depressive episode with episodes are not considered to be cases of PP.
postpartum onset (Ross, Dennis, Robertson Black- more, & Stewart, 2005). To classify as PPD, there The core feature of PP is mood disturbance, most must be a minimum period of 2 weeks in which the commonly mania, although women often £uctuate woman presents with depressed mood or loss of in- rapidly between elation and depression and show terest or pleasure in daily activities that represents a signi¢cant mood lability. Symptom onset is often change from normal behavior and causes impair- sudden and unexpected, usually occurring within ment in everyday functioning (APA, 2000). At least 48 hours to 2 weeks after giving birth (Brockington, four of the following symptoms must also be present 1996). While experts have reported that there is a for a diagnosis: weight change in absence of symptom-free period during the ¢rst 48 hours post- dieting, insomnia or hypersomnia, psychomotor partum (Brockington; Hamilton, 1962), more recent agitation or retardation, fatigue or loss of energy, research suggests that approximately one half of feelings of worthlessness or guilt, decreased ability women present with mild hypomanic symptoms to think or concentrate, and recurrent thoughts of within the ¢rst 3 days postpartum (Heron, McGuin- death or suicide (APA). The symptoms of PPD often ness, Robertson, Craddock, & Jones, 2008). The have a greater emphasis on childrearing and may clinical presentation of PP progresses rapidly include intrusive thoughts about harming their following these early mood symptoms, and is infant or feelings of guilt about being a poor mother.
characterized by delusions, hallucinations, bizarre behavior, and mood lability (Heron et al.). The na- Mild hypomanic symptoms in the early postpartum ture of the psychotic symptoms varies widely and often the delusions include religious themes. Visual, develop PPD (Heron, Craddock, & Jones, 2005).
auditory, and olfactory hallucinations have been re- Glover, Liddle, Taylor, Adams, and Sandler (1994) ported and can include commands to hurt oneself examined the early symptoms of PPD among 198 or the baby. Although it is generally agreed that the women and found that 50% who were hypomanic clinical presentation of PP is similar to mania or in the ¢rst 3 days postpartum experienced PPD at a¡ective psychosis independent of the postpartum 6 weeks, compared with only 18% of women who period, some researchers suggest that PP presents demonstrated no psychopathology. The postpar- with more severe confusion and perplexity (Brock- tum blues are often confused with PPD, despite the ington et al., 1981; Kirpinar, Coskun, C°ayk˛ylˇ, di¡erence in symptom severity, onset, and duration.
Anac°, & Úzer, 1999; Kisa, Aydemir, Kurt, Gulen, & Symptoms of PPD impair function, present through- out the ¢rst year postpartum, and persist for greater than 2 weeks in duration, while postpartum blues are often mild, transient, and present within the ¢rst few days after delivery (Brockington, 1996).
Epidemiologic studies demonstrate that women are more likely to be admitted to a psychiatric unit after giving birth than at any other time in their lives (Ken- The classi¢cation of PP is more complex, given dell et al., 1987; Munk-Olsen, Laursen, Pedersen, the range of symptoms that can occur and the fact Mors, & Mortensen, 2006). There has long been de- that the clinical picture can change rapidly. The bate as to whether the postpartum period is a time di¡erential diagnosis for PP episodes can include of increased risk for mood disorders. Although the major depression with psychotic features, bipolar I, overall prevalence of depression does not appear bipolar II, schizoa¡ective, unspeci¢ed functional to be higher in women after delivery as compared JOGNN, 38, 269-279; 2009. DOI: 10.1111/j.1552-6909.2009.01019.x Doucet, S., Dennis, C.-L., Letourneau, N. and Blackmore, E. R.
P R I N C I P L E S & P R A C T I C E Logsdon, Hertweck, Ziegler, & Pinto-Foltz, 2008; Murray, & Chapman, 1993), serious depression Logsdon & Usui, 2001). A woman’s relationship with requiring admission to hospital is clearly more prev- her partner is also a predictive variable (O’Hara & alent (Kendell et al.). Episodes of PPD and PP can Swain, 1996), with women who report lower levels occur with women who experience symptoms so- of satisfaction, quality, social integration, appraisal lely after childbirth; may represent the ¢rst episode support, problem-focused informational support, of a psychiatric disorder; or may be an exacerba- and higher levels of con£ict potentially at greater tion of a pre-existing psychiatric disorder (Baker, risk for developing PPD (Dennis & Ross, 2006).
Mancuso, Montenegro, & Lyons, 2002).
Additional risk factors include low self-esteem, childcare stress, severe maternity blues, infant temperament (Beck, 2001), and maternal fatigue The prevalence of PPD ranges across studies from 4.5% to 28% (Scottish Intercollegiate Guidelines Network, 2002). A frequently cited meta-analysis of 59 studies demonstrated that 13% of mothers expe- The incidence of PP resulting in hospital admission rience PPD within 12 weeks following delivery is approximately 1 to 2 in 1,000 deliveries (Kendell (O’Hara & Swain, 1996), while a more recent report et al., 1987; Munk-Olsen et al., 2006). Women who suggests rates as high as 15% in community sam- have a history of bipolar disorder are particularly ples (Gaynes et al., 2005). The variability in rates vulnerable to experiencing PP, with rates between can be attributed to sampling, timing of assessment, 25% and 50% (Brockington, 1996; Jones & Crad- di¡erent diagnostic criteria, and whether the study is dock, 2001). A personal history of PP predisposes retrospective (lower rates) or prospective (higher approximately 57% of women to experience an- rates) (Dennis & Hodnett, 2007). While PPD can other episode after a subsequent pregnancy occur within the ¢rst year postpartum (Goodman, (Gar¢eld, Kent, Paykel, Creighton, & Jacobson, 2004), rates often peak at 12 weeks (Gaynes et al.).
2004; Pfuhlmann, Franzek, Beckmann, & St˛ber, Meta-analyses including prospective studies have consistently demonstrated that women who have There is increasing evidence to support the role of a history of depression and experience depression genetics in PP (Coyle, Jones, Robertson, Lendon, or anxiety during pregnancy are at increased risk & Craddock, 2000; Jones & Craddock, 2007). Par- for developing PPD (Beck, 2001; O’Hara & Swain, ticularly interesting is the extremely high risk of PP 1996; Robertson, Grace, Wallington, & Stewart, (74%) in parous bipolar women who also have a 2004). Research also shows that a family history of ¢rst-degree relative with a history of PP (Jones & psychiatric illness increases the risk of PPD (Steiner, Craddock, 2001). No speci¢c gene has yet been 2002). The rapid decline in reproductive hormones shown as placing women at greater risk for PP, al- (e.g., estrogen and progesterone) and altered though advances in research are promising in this cytokines pro¢les that follow after delivery are direction (Jones & Craddock). Rapid hormonal suggested to play a role in the development of de- changes after pregnancy are suggested to play a pressive symptoms in women who are susceptible role in the development of PP. There is evidence that (Bloch et al., 2000; Groer & Davis, 2006; Wisner, changes in the levels of estrogen, prolactin, proges- Parry, & Piontek, 2002). While biological factors terone, adrenocorticoids, and thyroid hormones potentially contribute to vulnerability of developing precede the onset of PP, although the evidence PPD, there is no clear evidence to identify one cau- remains equivocal (Brockington, 1996; Seyfried & sal biochemical or hormonal factor (Gentile, 2005; Seyfried & Marcus, 2003). Moreover, it has been suggested that biological factors play an indirect Primipara women are consistently reported to be at role in the development of depressive symptoms as greater risk of experiencing PP (Agrawal, Bhatia, & a mediator through psychosocial factors (Ross, Malik, 1997; Kendell et al., 1987; Kisa et al., 2007; Sellers, Gilbert Evans, & Romach, 2004).
Robertson Blackmore et al., 2006; Videbech & Gouliaev, 1995). Kendell and colleagues demon- Several psychosocial variables have been reported strated that this ¢nding was not explained by age as contributing factors in the development of PPD. In or the avoidance of future pregnancies among particular, stressful life events and low levels of per- women who experience an episode of PP after their ceived social support are consistently associated ¢rst pregnancy. In a more recent study, however, with increased risk (Dennis & Letourneau, 2007; ¢rst-time mothers who were older had a greater risk P R I N C I P L E S & P R A C T I C E Postpartum Depression and Postpartum Psychosis of developing PP, with women between the ages of visits (Armstrong, Fraser, Dadds, & Morris, 1999) 40 and 44 at greatest risk (Nager, Johansson, & and midwifery home visits that are £exible, individu- Sundquist, 2005). This ¢nding has important impli- alized, and utilize PPD screening tools (MacArthur cations, given that many women are waiting longer et al., 2002). Telephone-based peer support also to start having children. Women who experience has the potential to decrease the risk of depressive sleep loss also appear to be particularly vulnerable symptomatology among mothers (Dennis, 2003).
to the development of PP (Sharma & Mazmanian, Dennis and Creedy reported that preventive inter- ventions targeting women considered to be at risk were more e¡ective in preventing PPD than Other risk factors for PP include living in a poor socioeconomic neighborhood (Nager, Johansson, population. The e⁄cacy of antidepressants in & Sundquist, 2006), having a female child (Agrawal et al., 1997; Kendell et al., 1987), delivery by Cesarian Ho¡brand, Henshaw, Boath, & Bradley, 2005).
section (Kendell et al.), complications during delivery (Robertson Blackmore et al., 2006), preterm delivery, low birth weight (Videbech & Gouliaev, 1995), and Psychosocial and psychological interventions are perinatal death (Kendell et al.). Evidence to support frequently used in the treatment of PPD. Many wo- these risk factors is inconclusive, as other research- men prefer nonpharmacological interventions, due ers have reported insigni¢cant ¢ndings for the same to the potential transmission of medication into risk factors (Kendell et al.; Robertson Blackmore breast milk, fear of addiction or dependence, or ad- et al.; Videbech & Gouliaev). Research on marital verse side e¡ects (Dennis & Chung-Lee, 2006). A recent Cochrane review evaluated the e¡ect of psy- demonstrating that married women are at greatest chosocial and psychological interventions on the risk (Kirpinar et al.,1999; Protheroe,1969), while other treatment of PPD and found that nondirective coun- research suggests that unmarried women are at seling, cognitive behavioral therapy, interpersonal higher risk (Kendell et al.; Nager et al., 2005). The psychotherapy (IPT), psychodynamic therapy, and close timing of PP to childbirth, sudden onset, rela- telephone-based peer support may all be e¡ective tive dissociation from social consequences, high treatment options (Dennis & Hodnett, 2007). Inter- relapse rate (Murray, Cooper, & Hipwell, 2003), and personal psychotherapy is also e¡ective as a long- consistent prevalence cross-culturally (Kumar, 1994) term support measure to prevent future episodes of all point to a biological etiology of PP.
depression (Stuart & O’Hara,1995). In an earlier com- prehensive review conducted by Dennis (2004), the potential bene¢cial treatment e¡ects of peer and partner support, massage therapy, infant sleep inter- Both PPD and PP are highly treatable disorders, ventions, mother-infant relationship therapy, and and given that they are not considered to be quali- maternal exercise were also reported. As many of tatively di¡erent than depression and mania or the trials evaluating PPD treatment interventions in a¡ective psychosis outside the postpartum period, this review had signi¢cant methodological limita- there is no evidence to suggest that interventions tions, the results should be interpreted with caution.
outside the postpartum period would not be as While psychosocial and psychological treatment e¡ective postnatally. Prevention and treatment in- options are important, many women also require terventions for women experiencing postpartum pharmacotherapy. The e¡ects of antidepressants mood disorders are guided by severity of symptoms, are the same as for general depression; however, underlying mental illness, past response to treat- for PPD there is the additional consideration of ment, women’s preferences, and breastfeeding whether the mother is breastfeeding (Seyfried & status (Nonacs & Cohen, 1998; Sit, Rothschild, & Marcus, 2003). The treatment e¡ects of hormones (e.g., estrogen and progesterone) remain equivocal (Ahokas, Kaukoranta, Wahlbeck, & Aito, 2001; Gregoire, Kumar, Everitt, Henderson, & Studd, 1996; Based on a Cochrane meta-analysis conducted by Dennis and Creedy (2004), there are no prenatal psychosocial or psychological interventions that can be empirically recommended for the preven- tion of PPD. There is preliminary support, however, Research on the prevention of PP is primarily limited for the e¡ects of weekly postpartum nursing home to pharmacotherapy. Given the association of PP JOGNN, 38, 269-279; 2009. DOI: 10.1111/j.1552-6909.2009.01019.x Doucet, S., Dennis, C.-L., Letourneau, N. and Blackmore, E. R.
P R I N C I P L E S & P R A C T I C E with bipolar disorder, mood stabilizers such as lith- at greater risk for relapses postnatally, but not at ium are commonly used as a prophylactic measure increased risk for nonpostpartum episodes. In and dramatically reduce the risk of a relapse post- contrast, they found that women who had previous natally (Cohen, Sichel, Robertson, Heckscher, & episodes of depression had increased risk for non- Rosenbaum, 1995; Stewart, Klompenhouwer, Ken- dell, & van Hulst, 1991). Further support for the use of lithium is based on studies demonstrating high relapse rates among women who discontinue cur- rent use (Viguera et al., 2000). The prophylactic Outcome studies of PP show stability between the e¡ect of olanzapine was demonstrated in one open initial clinical presentation of postpartum episodes clinical trial (Sharma, Smith, & Mazmanian, 2006), and lifetime diagnosis (Protheroe, 1969; Robling, while the prophylactic use of hormone therapy Paykel, Dunn, Abbott, & Katona, 2000). For exam- (e.g., estrogen) remains equivocal (Kumar et al., 2003; Sichel, Cohen, Robertson, Ruttenberg, & postpartum mania and experiences a subsequent psychiatric episode usually continues to experi- ence a bipolar illness. The majority of women who experience PP have favorable outcomes with full re- There is a dearth of treatment trials on PP and the covery. The prognosis of PP is better than for majority of research to date consists of case re- women who experience mania or psychosis out- ports. Because of the severity of PP, hospitalization side the postpartum period (Kirpinar et al., 1999); is often required and interventions are predomi- however, relapses are common. It is estimated that nantly biological in nature. Pharmacotherapy is the 62% of women who experience PP su¡er a subse- ¢rst line of treatment and preliminary evidence quent a¡ective episode outside the postpartum supports treatment with mood stabilizers and period, while approximately 57% experience a re- lapse after a subsequent pregnancy (Robertson et therapy is also e¡ective in treating severe and al., 2005). There is also a high risk of suicide, a¡ect- treatment-resistant cases of PP (Forray & Ostro¡, ing approximately 4% of women who experience 2007). The e¡ects of antidepressants in the treat- PP (Pfuhlmann, Stoeber, & Beckmann, 2002).
ment of PP with primarily depressive features are not well researched and caution is warranted due Psychosis solely in the postpartum period is asso- to the risk of antidepressants causing rapid cycling ciated with the best outcomes in terms of illness, Williams, & Brockington, 1989), although only 20% experience no further psychopathology (Pfuhlm- ann et al., 1999; Schopf & Rust, 1994). A family history of mental illness predicts a shorter time to recurrence outside the postpartum period (Rob- Numerous studies have examined the long-term outcomes of PPD. Most women who receive treat- ment recover within 12 weeks (Cooper & Murray, 1995), while up to 15% of women will continue to ex- perience depressive symptoms for greater than 24 Table 1 outlines the principle di¡erences between weeks (Cooper, Campbell, Day, Kennerley, & Bond, PPD and PP with respect to the prevalence, risk fac- 1988). The course of PPD is often prolonged tors, onset, symptoms, management, and long-term because of a delay in diagnosis or inadequate outcomes of these disorders. A noticeable di¡er- treatment (Scottish Intercollegiate Guidelines Net- ence is the prevalence and onset times. The risk work, 2002). Stigma and shame frequently prevent factors for both PPD and PP are complex and multi- women from obtaining the required treatment (Beck, 2002; Dennis & Chung-Lee, 2006; Letourn- psychosocial factors, PP is generally predicted by eau et al., 2007). Women who experience PPD biological factors. The approach to treatment also are prone to relapses, with at least 25% of women di¡ers. Postpartum depression is most commonly managed by a primary health professional (e.g., (Wisner et al., 2002) and 41% relapsing after a family physician and public health nurse) and oc- subsequent pregnancy (Wisner, Perel, Peindl, & casionally by a psychiatrist if resources exist, while Hanusa, 2004). Cooper and Murray found that PP is routinely managed in the hospital. The treat- women who had no prior history of depression were ment of PPD often includes psychosocial and P R I N C I P L E S & P R A C T I C E Postpartum Depression and Postpartum Psychosis Note. ECT 5electroconvulsive therapy.
Improved recognition of at-risk women and early detection of postpartum mood disorders is essen- tial, considering the high prevalence and potential adverse consequences. Nurses can play an integral role in educating women and their families prena- tally about potential risk factors, early signs, and appropriate prophylactic measures. Women who experience anxiety or depressive symptoms in the prenatal period should be followed closely, as these symptoms are consistently predictive of PPD. De- tailed personal and family psychiatric histories should be obtained from all women. The woman’s family members are key informants ; therefore, nurses should ask family members about changes psychological interventions, while biological strate- in the woman’s mood or behavior. Health profes- sionals should also be aware that women who present without risk factors may still develop PPD Childbearing women encounter nurses working in a variety of settings. Accordingly, nurses are ideally Postpartum depression is often more di⁄cult to de- placed to screen, assess, and treat women experi- tect than PP, as many symptoms of depression are similar to somatic symptoms that normally occur JOGNN, 38, 269-279; 2009. DOI: 10.1111/j.1552-6909.2009.01019.x Doucet, S., Dennis, C.-L., Letourneau, N. and Blackmore, E. R.
P R I N C I P L E S & P R A C T I C E after childbirth. For example, weight and sleep dis- turbances are normal for women postpartum, but Improved recognition of at-risk women and early detection are also symptoms of depression. To elucidate of postpartum mood disorders is essential, considering the whether changes in weight are a symptom of de- high prevalence and potential adverse consequences.
pression, nurses can ask women about their desire for food and if they continue to enjoy their favorite foods (Ross et al., 2005). Sleep disturbances can score for each of the seven scales, and the be assessed by asking women if they are able to rest corresponding manual provides guidelines for or sleep when given the opportunity (Ross et al.).
interpreting scores on each of the scales. The scale Fatigue is also di⁄cult to assess. Fatigue associ- can be used as a screening instrument for PPD from ated with depression is a continual state of 2 weeks after delivery, and Beck and Gable recom- exhaustion, despite the amount of sleep or rest ob- mended readministering the PDSS every 3 months during the ¢rst 12 months postpartum.
The Edinburgh Postnatal Depression Scale (EPDS) When screening for PP, nurses should look for signs is a 10-item instrument used internationally to of mood lability, euphoria, confusion, disorganiza- assess for PPD, and excludes questions about tion, delusional beliefs, hallucinations, and suicidal somatic discomforts (Cox, Holden, & Sagovsky, or homicidal ideations. Continual assessment of 1987). This standardized instrument is a self-report woman’s sleep pattern is also important, as insom- measure that assesses how postpartum women felt nia may represent an early symptom of PP (Sharma during the past 7 days. The EPDS takes only 5 min- & Mazmanian, 2003). Assessing for early hypoman- utes to administer, is free of charge (Horowitz & ic signs within the ¢rst 3 days postpartum is also Goodman, 2005), and is readable at the third-grade important, as these symptoms are predictive of both level (Logsdon & Hutti, 2006). It has been validated PPD and PP. These early signs can be di⁄cult to in several di¡erent languages and cultures (DeRo- detect, as many women perceive that they are sim- sa & Logsdon, 2006). It should be noted that the ply coping extraordinarily well (Heron et al., 2008).
EPDS is not a diagnostic instrument or a replace- The Mood Disorder Questionnaire (MDQ) is one in- ment for diagnostic assessment, rather the EPDS is strument that can be used to assess for symptoms used to provide information on the severity of PPD of hypomania and mania (Hirschfeld et al., 2000).
symptoms (McQueen, Montgomery, Lappan-Gra- The MDQ is a free self-report questionnaire that con, Evans, & Hunter, 2008). While the best time to screens for bipolar disorder with 13 yes/no items administer the EPDS is unknown (McQueen et al.), derived from both DSM-IV criteria and clinical it has been recommended that the EPDS be admin- experience (Hirschfeld et al.). All questions begin istered anytime throughout the postpartum year to with the statement ‘‘Has there ever been a period of con¢rm depressive symptoms (Registered Nurses time when you were not your usual self and . . .’’ Item Association of Ontario, 2005). Women who report a examples include ‘‘you felt much more energy than score of 1 or greater on thoughts of self-harm (item usual’’ and ‘‘thoughts raced through your head or 10) require immediate attention (Registered Nurses you couldn’t slow your mind down.’’ The MDQ has Association of Ontario), and appropriate treatment been translated into several di¡erent languages and referral mechanisms must be in place.
and is validated for use in psychiatric and general populations (Chung, Tso, Cheung, & Wong, 2008).
While the MDQ is a screening instrument, it has a (PDSS) (Beck & Gable, 2002) is a 35-item self-re- sensitivity of .73 and speci¢city of .90 against the port scale, consisting of statements about how the DSM-IV diagnosis of bipolar disorder in a psychiat- mother may be feeling after the birth of her baby.
The PDSS needs to be purchased, is written at a Research has demonstrated that the MDQ may be third-grade reading level and takes 5 to 10 minutes less e¡ective with patients who have impaired in- to complete. Statements relate to the previous 2 sight or milder bipolar spectrum conditions (Miller, weeks and responses are given on a 5-point Likert Klugman, Berv, Rosenquist, & Ghaemi, 2004).
scale ranging from ‘‘strongly disagree’’ to ‘‘strongly agree.’’ Higher scores indicate higher levels of post- partum depressive symptoms. The scale comprises Once symptoms of PPD or PP are recognized, a seven symptom content areas including: sleeping/ complete medical history should be obtained and eating disturbances, anxiety/insecurity, emotional a full diagnostic workup completed to rule out other lability, mental confusion, loss of self, guilt/shame, potential causes, such as thyroid dysfunction, dia- and suicidal thoughts. The PDSS yields a separate betes, anemia, or autoimmune diseases (Ross P R I N C I P L E S & P R A C T I C E Postpartum Depression and Postpartum Psychosis et al., 2005). Assessment of the woman’s safety and can occur, given the high refusal rates for this treat- the safety of her child(ren) is of highest priority, as women may experience suicidal or homicidal ideat- psychotic women. Women and their families should ions. Inquiring about thoughts of suicide is required be informed of the bene¢ts and risks of treatment and any thoughts of self-harm should be taken se- when breastfeeding. In particular, a discussion riously. Women should also be continually assessed weighing the risks of untreated symptoms, particu- for their thoughts and feelings toward their infant, larly with respect to maternal-infant relationships as hallucinations and delusions, compounded with and child development (Beck, 1995, 1999), with the feelings of irritability and di⁄culty in controlling risks of medication being transferred into breast emotions, can lead to thoughts of infant harm. The milk must be clearly explained so that informed de- partners of women diagnosed with postpartum cisions about treatment and breastfeeding can be mood disorders could also be assessed for symp- made (Viguera et al., 2000). Health professionals toms of depression, given that maternal depression play a critical role in monitoring for adverse e¡ects is a signi¢cant risk factor for paternal depression resulting from treatment (Wisner et al., 2002). Moni- postnatally (Ballard, Davis, Cullen, Mohan, & Dean, toring for adverse e¡ects in infants who are Psychosocial and psychological treatment inter- ventions are also important. It is widely known that Timely treatment is important in order to prevent an the women who experience postpartum psychiatric increase in symptom severity. Unfortunately, many disorders who have more support have better out- women who experience symptoms of PPD or PP comes. For example, women diagnosed with PPD are reluctant to seek help (Dennis & Chung-Lee, who receive support from their partners have de- 2006; Kersting, Fisch, & Arolt, 2003) due to shame, creased depressive symptoms (Misri, Kostaras, Fox, fear (real or imagined) that their children will be ta- & Kostaras, 2000) and shorter hospital stays ken away, a lack of insight into the seriousness of (Grube, 2005). Unfortunately, women who experi- their illness, or simply because appropriate forms of health care services are either not available or strained relationships with their partner, family, and not easily accessible (Dennis & Chung-Lee; Leto- friends. During discharge planning, it is important to urneau et al., 2007). Prenatally and before hospital ensure that women and their families have ade- discharge, postpartum women could be informed quate support and resources in the community, as of the available services to access if symptoms de- well as appropriate follow-up care. As such, nurses velop and could be educated about the serious require a good understanding of what services are available in the community for women experiencing postpartum mood disorders. Family members can Central to the treatment plan is educating the be taught therapeutic communication techniques, a¡ected women and their families. Given the such as active listening and empathy, so they can misconceptions portrayed in the media of women appropriately provide support during the recovery who experience mental health issues postnatally, period (Ugarriza,1992). Nurses who have advanced women and their families should be educated training in psychiatric mental health nursing (e.g., about the potential causes, symptoms, and ex- nurse practitioners and clinical nurse specialists) pected course of the illness. Any misconceptions are especially quali¢ed to provide mental health or fears could be addressed at this time. Women treatment, such as IPT (Horowitz & Goodman, should also be aware of the high rates of recurrence after subsequent pregnancies and outside the postpartum period, as many women are not in- Postpartum depression and PP are complex mood formed of these risks (Robertson et al., 2005).
disorders that require interdisciplinary and biopsy- Guidance can be o¡ered on how to prevent or rec- chosocial approaches to care that address the ognize early symptoms of mood disorders. It is needs of a¡ected women and their families. Nurses important for women to be aware that avoiding fur- and other health professionals need to keep up-to- ther pregnancies will not guarantee preventing date with current research, in order to provide the most appropriate and bene¢cial care throughout the perinatal period. Improved training in under- Educating on the treatment regime is essential to graduate programs would provide the foundation ensure compliance. An open discussion on any necessary to care for this vulnerable population.
fears or concerns with using pharmacotherapy Nurses can advocate that postpartum mood disor- JOGNN, 38, 269-279; 2009. DOI: 10.1111/j.1552-6909.2009.01019.x Doucet, S., Dennis, C.-L., Letourneau, N. and Blackmore, E. R.
P R I N C I P L E S & P R A C T I C E ders receive a greater place in nursing curriculums, as well as for ongoing educational programs for all Postpartum depression and psychosis are complex mood disorders that require interdisciplinary and biopsychosocial approaches to care that address the needs of affected women and their families.
ConclusionPostpartum depression and PP are severe and de- bilitating disorders that a¡ect women at a crucial Beck, C. T. (2001). Predictors of postpartum depression: An update. Nurs- time. Given that women are often in contact with health care services throughout the perinatal Beck, C. T. (2002). Postpartum depression: A metasynthesis. Qualitative period, this represents an excellent window of opportunity for nurses to screen for PPD and PP Beck, C. T., & Gable, R. K. (2002). Postpartum depression screening scale and to assist in implementing preventative and manual. Los Angeles: Western Psychological Services.
treatment measures. Early identi¢cation and appro- Bloch, M., Schmidt, P. J., Danaceau, M., Murphy, J., Neiman, L., & Rubinow, priate and timely treatment are critical to the well- D. R. (2000). E¡ects of gonadal steroids in women with a history of being of the a¡ected woman and her family. Collab- postpartum depression. American Journal of Psychiatry, 157, 924- oration among all health professionals is essential Brockington, I. F. (1996). Motherhood and mental health. Oxford: Oxford in order to detect and most e¡ectively manage wo- men experiencing postpartum mood disorders.
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Figures and Tables Fig.1. Simplified flowchart for American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) 2009 glycemic control algorithm. Pathways are provided for patients with hemoglobin Ale (A1C) in 3 ranges: 6.5% to 7.5%, >7.6% to 9.0%, and >9.0%. There is a progression from rnonotherapy, to dual therapy, to triple therapy, to insulin the

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