Title: Post Partum Depression an Investigative Review

Carly Malpass

10216525

Title: Post Partum Depression an Investigative Review

Background

Depression is twice as likely to develop in women as men throughout the world’s population (3). As childbirth is a major life event that can potentially be very stressful for women it poses as a period where mental health can be challenged (5). Post partum depression is a common mood disorder that affects women throughout pregnancy and during the period after childbirth (5). As this is an illness that is widely spread there is great importance in screening and diagnosing women during the antenatal period to ascertain whether or not they will be at risk of developing post partum depression. Depending on the severity of post partum depression there are a number of common outcomes for those cases that go untreated; these include personal suffering to the mother and family, poor mother-infant relationships, impaired emotional development of the children and in most severe cases infanticide and maternal suicide (1). As there are clearly defined symptoms associated with the development of post partum depression predictive models have been developed so that effective screening and subsequent diagnosis can be practiced (5). The early detection of post partum depression allows for intervention to take place and affected parents can begin treatment and management plans to rectify their condition (6). As women have multiple contacts with health professionals throughout their pregnancy then implantation of screening instruments should not be difficult, however post partum depression is still severely under diagnosed throughout the western world (1). The prevalence of the disease fluctuates greatly across many studies ranging from 3% to 25% amongst pregnant women; these differences show the need for the implementation of a universal method of screening and diagnosis (5).

Currently there are two common predictive models that are used as screening instruments that yield similar results; these are the Edinburgh Postnatal Depression Scale (EPDS) and the Post Partum Depression Screening Scale (PDSS). These models are used to determine if a woman is at risk of developing post partum depression and the degree of PPD that she is likely to suffer.

The Post Partum Depression Screening Scale

The PDSS is a self report questionnaire that is designed to gain information from the mother about her sleeping and eating patterns, her feelings of anxiety and insecurity, cognitive impairments, loss of self esteem and whether or not she could have intention to harm herself (1). The answers to the questionnaire that the participant gives form a continuum like structure of post partum diagnosis, that is answers range from strongly agrees to strongly disagree (1). The PDSS instrument is followed up by an interview performed by a clinically trained professional, this person is educated about maternal care and the post partum illness. The interviewer is blinded to the patients result from the questionnaire (1). The results produce the patient with a score that lies on a continuum, many studies have recognized that people presenting with major post partum depression are twice as high as those who do not show depressive tendencies (1). A study that used the PDSS as a method of screening for the post partum disorder recognized that the most common symptom amongst all levels of PPD was anxiety and that intention to kill or harm oneself was the least common symptom associated with post partum depression, with those who are diagnosed at risk of developing major post partum depression there are typically a great deal of strongly agree answers (1). Women who are at risk of developing a minor level post partum depressive state tend to have less emotional lability when they speak of their maternal roles (1). As it has high sensitivity and specificity the PDSS instrument offers a reliable and valid method of screening for post partum depression allowing early detection (1).

The Edinburgh Postnatal Depression Screen

This is an instrument that is used to screen for post partum depression over a series of time after childbirth, this allows for symptoms to be followed up and severity of the illness to be determined. The EPDS uses predictive models of common symptoms to measure PPD at 1 week post partum and generally again at 6 weeks (5). The EPDS is a 10-item self reporting tool that offers high sensitivity and high specificity which result in the predictive power of the instrument being positive for diagnosing cases of post partum depression (5). The EPDS focuses on risk factors including socio-demographic, biologic, pregnancy related, life stressors, social support, maternal adjustment factors as well as personality and self esteem measures to predict post partum depression tendencies (5). Studies performed in Japanese, UK, Irish and Canadian populations have recognized a positive relationship between the symptoms that one presents at the one-week post partum period and again at the 6-week post partum period (5). Studies have indicated that mothers who have an initial one-week EPDS score that is greater than nine are at a much greater chance of having the same score when they are followed up at eight-week period (5).

Discussion

As there are clearly defined symptoms associated with the development of post partum depression the obstacle of early detection and subsequent treatment and future prevention is not huge (1). Mothers need to be screened throughout the antenatal period so that the risk of post partum depression developing is reduced and where necessary treatment can be implemented (4). Mental illness is common amongst all walks of life, however education on the subject is lacking and people associate a major stigma with the suffering of depressive disorders. By educating mothers/parents throughout their pregnancies about what post partum depression is people experiencing symptoms can seek help from health professionals to combat the illness and thus reduce the overall prevalence of women suffering post partum depression after childbirth (6). The risk of developing the post partum depression disorder can be effectively detected using the Postnatal depression Screening Scale and the Edinburgh Postnatal Depression Screen, each of which offer high sensitivity and specificity in testing and show positive predictive power which leads to valid and reliable results. These screening instruments are very similar in nature. In reality either tool could effectively be implemented at a universal level. The results of many studies looking at the risk factors for developing post partum depression recognize that sleeping and eating disturbances, fatigue, feelings of guilt, intention to harm, obsessiveness, loss of self, insecurity and a sense of loneliness are correlated with the development of PPD (1). However as many studies are focused primarily on middle classed white women there is a need for future studies to determine whether the same risk factors are positively correlated throughout all racial and ethnic backgrounds and men.

So Far……..

There have been limited studies that look at the possibility of differences across racial and ethnic backgrounds; the studies that have taken place have yielded results that indicate neglect in knowledge about the immediate health of the mother and infant after birth (9). The idea that people from different racial and ethnic backgrounds could have different predictive symptoms for post partum depression is not unreasonable. People of differing races differ in their exposure to environmental stressors, which in turn would lead to them experiencing different symptoms for post partum depression (9). Amongst ethnic groups access to health care and understanding of the illness play a vital role in the early detection and treatment of post partum depression. In the limited studies that have investigated the association between post partum depression and race and ethnicity it has been recognized that there is an independent association between race and the risk of developing post partum depression after childbirth. Results have shown that African American women have an odds ratio of 2.16, Hispanic women an odds ratio of 1.89 of developing PPD compared with white women, all of which were significant (9). This means that African American women and Hispanic women are 2.16 and 1.89 times more likely to develop post partum depression after childbirth than are white women. It should be noted that we must take note of the manner in which the term race has been used in these studies, it is used loosely as a way of describing socio-cultural differences and does not mean that there are genetic differences for different racial groups but rather there are different cultural factors that can influence the development of post partum depression.

Post partum depression is a mental disorder that can primarily be associated with situational factors such as environmental stressors that arise after childbirth. Keeping this in mind it is reasonable to assume that the illness can affect males as well. Most studies see the father as an invisible entity during the first year post partum (8). However recent social transitions of equality between men and women have led to an increase in the number of men who are staying home and taking on the maternal care giver role. As an active part of the parenting process then it is likely that males will share many of the symptoms that females at risk of PPD development present with. If men are experiencing these environmental stressors then when will they be detected? This shows the need for more research to be conducted to determine the link between males who act as primary care givers and their risk of developing PPD.

So in order for a universal screening instrument to be implemented it is important that knowledge about all cases of post partum depression is investigated. This is especially important in terms of socio-cultural ethnic differences and sex differences in the epidemiology of the illness. By investigating all avenues of the illness education and key prevention strategies can be put in place to help those people that are at a large risk of developing the depressive disorder.

Reference

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