Detection and Management of Postpartum Emotional Disturbance in Primary Care Practice
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I practice family medicine within fifteen miles of the US Capitol “Inside the Beltway.” Our local news often holds national attention and it happened again recently. A 34-year-old woman reported to have had postpartum depression complicated by psychosis tried to ram her car into both the White House and Capitol grounds and ended up shot to death by Federal officers. The facial expression of the officer as her infant daughter was taken out of the car seat in the back of that car summarizes the horror, confusion, and disbelief that such an incident produces. [1,2]
Col. (Ret) Elspeth Cameron-Ritchie,  chief clinical officer for the District of Columbia Department of Mental Health, warned those attending a meeting earlier that week on military electronic health records, that the Nation’s Capital is a magnet drawing those whose delusions involve the Federal government. That her prediction would come true within days of her statement was phenomenal.
A majority of women experience some emotional lability within the month surrounding childbirth characterized by crying for no reason, anxiety, and irritability. The normal “baby blues” usually resolves within a few weeks of delivery; however the presence of emotional disturbance may be predictive of the development of clinical mood disorders. A prospective survey of over 850 new mothers in Germany found that there was a 4-fold increased risk of affective disorders with symptomatic “baby blues”.  A recent survey of 10,000 new mothers in a U.S. urban university hospital setting found that almost 15% screened positive for postpartum depression and, of these, one in five had thoughts of self-harm. 
Although there are no US national clinical practice guidelines for primary care detection and management of postpartum emotional disorders, the Department of Veterans Affairs and the Department of Defense (VA/DoD) Clinical Practice Guidelines for the Management of Major Depressive Disorder recommends routine depression screening in primary care practice at the first antenatal and postnatal visits and again 3 to 4 months postnatal.  “BeyondBlue,” an Australian guideline for primary care practice, recommends that each practice develop a strategy to assess women during pregnancy as well as 6-12 weeks after birth for symptoms of emotional distress as well as sources of psychosocial support.  Barbara Yawn’s work with the American Academy of Family Physicians Research Network suggests that the first postpartum checkup or the first well-baby visit is an ideal opportunity for screening, but there is evidence that women may be at risk for postpartum depression for at least a year after childbirth. She cautions that continuing clinical awareness is essential for healthcare professionals. 
A validated screening instrument, the Edinburgh Postnatal Depression Scale (EPDS), is a self-administered scale with ten questions which addresses guilt, anhedonia, insomnia, anxiety, sadness, hopelessness, and suicidal ideation. It can be reproduced and distributed with appropriate attribution of sources and is available for download in English and Spanish. [9,10] There also is an EPDS online tool for self-administration and scoring. There are ongoing studies utilizing general depression screening instruments such as the Patient Health Questionnaire (PHQ-9) and possibly using the PHQ-2 question version as a sequential approach to screening.  Following the VA/DoD guideline, I use the PHQ-2 for initial screening during pregnancy and postpartum and follow with the EPDS if the PHQ-2 is positive.
Regarding intervention, a recent Cochrane Collaboration systematic review found that peer-based peripartum telephone support was beneficial.  In general, therapeutic interventions for depression were found to be similarly effective for postpartum depression. These include healthcare home visit programs and psychotherapy used in conjunction with pharmacotherapies. Antidepressants are frequently prescribed for postpartum depression although the evidence of benefit is less robust than for other mood disorders.  Among the selective serotonin reuptake inhibitors (SSRI) used commonly in primary care treatment of depression and anxiety, paroxetine and sertraline have the lowest concentration in breast milk, however all of them have been used safely and effectively during lactation. 
The dramatic changes in steroid hormone levels during pregnancy and parturition have long been assumed to have a role in the development of postpartum mood disorders. A pilot study suggests that an estrogen receptor gene allele (ERS1 TA) apparently has an interaction with serotonin transporter genes and its frequency is significantly associated with increased EPDS scores.  There is substantial work in animal models of mood disorders suggesting that decreasing estrogens are correlated with increased dysfunctional behavior and that estrogen replacement may reduce that dysfunctional behavior. 
Postpartum psychosis is sufficiently uncommon that there is little systematic evidence on its etiology, prevention, and treatment.  Unfortunately we have ample evidence of the suffering that it can cause individuals, families, and communities. The question remains, could this woman’s delusions have been mediated by a psychotropic medication prior to her psychotic breakdown?
Charles Sneiderman MD PhD DABFP
Family Physician and Medical Director
Culmore Clinic, Falls Church, VA
Published on December 17, 2013
Charles Sneiderman, MD PhD, retired in 2010 after a 31-year career in medical informatics at the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health. His work included research and development in telemedicine, distance learning, and medical language and image processing. Since leaving federal service, he has developed a computerized clinical decision support system to assist primary healthcare practices in the recognition and management of post-traumatic stress syndromes with support from the NLM Disaster Information Management Research Center. Dr. Sneiderman received a B.S. with high honors from the University of Maryland in 1969, and M.D. and Ph.D. degrees from Duke University in 1975 and completed residency training in family medicine at the Medical University of South Carolina in 1979. He has authored numerous scientific reports, book chapters, and medical educational media. Dr. Sneiderman was a Clinical Assistant Professor of Family Practice at the Uniformed Services University of the Health Sciences and maintains certification by the American Board of Family Medicine. He has practiced family medicine part-time in the Washington, DC area since 1980. He has assisted wounded warriors with adaptive snowsports since 2005.
- Goldman R, et al. Miriam Carey, Capitol Suspect, Suffered Post-Partum Depression. ABC News report. October 3, 2013. http://abcnews.go.com/US/miriam-carey-capitol-suspect-suffered-post-partum-depression/story?id=20465157
- Freidman D, et al. Connecticut woman Miriam Carey suffered ‘postpartum depression’ after having baby before crashing White House gate, mom says. New York Daily News. October 3, 2013. http://www.nydailynews.com/news/national/shots-fired-u-s-capitol-report-article-1.1475378#ixzz2gldYev3c. Accessed December 4, 2013.
- Elspeth Cameron Ritchie, author bio at Times USA. http://nation.time.com/author/ecritchie/
- Reck C, Stehle E, Reinig K, Mundt C. Maternity blues as a predictor of DSM-IV depression and anxiety disorders in the first three months postpartum. J Affect Disord. 2009 Feb;113(1-2):77-87.
- 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 May;70(5):490-498.
- Susskind O, Cassidy C, Craig TJ, Engel C, et al; the management of MDD working group. VA/DoD Clinical practice guideline for management of major depressive disorder (MDD). May, 2009. http://www.healthquality.va.gov/Major_Depressive_Disorder_MDD_Clinical_Practice_Guideline.asp
- Austin M-P, Highet N, Guidelines Expert Advisory Committee. Australian clinical practice guidelines for depression and related disorders — anxiety, bipolar disorder and puerperal psychosis — in the perinatal period. A guideline for primary health care professionals. Melbourne (Australia): beyondblue: the national depression initiative; Feb 2011. http://www.beyondblue.org.au/resources/health-professionals/clinical-practice-guidelines/perinatal-clinical-practice-guidelines
- Gjerdingen DW, Yawn BK, Postpostpartum Depression Screening: Importance, Methods, Barriers, and Recommendations for Practice. J Am Board Fam Med. 2007 May-Jun;20(3):280-288. http://www.jabfm.org/content/20/3/280.long#content-block
- Edinburgh Postnatal Depression Scale 1 (EPDS). http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
- Escala Edinburgh para la Depresión Postnatal (Spanish Version). http://www.cdph.ca.gov/programs/mcah/Documents/MO-CHVP-EPDS-Spanish.pdf
- Larocco-Cockburn A, Reed SD, Melville J, Croicu C, Russo JE, Inspektor M, Edmondson E, Katon W. Improving depression treatment for women: Integrating a collaborative care depression intervention into OB-GYN care. Contemp Clin Trials. 2013 Aug 9;36(2):362-370.
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