By Abby O. Lozano, MD, Kristin Park and Emily Liu

Peripartum Depression:

Clinical Medical Students’ Reflections

By Kristin Park, Emily Liu and Abby O. Lozano, MD

Peripartum depression is defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, as a major depressive episode during pregnancy or occurring in the four weeks after delivery. Clinical features include depressed mood or anhedonia, with four additional symptoms: sleep disturbances, excessive guilt, low energy, concentration difficulties, appetite changes, psychomotor agitation or retardation and suicidal ideation. Postpartum depression affects approximately 10-15% of adult mothers yearly and rates are particularly high in adolescent (25%) and African American (35%) mothers.

Delayed medical and psychiatric care can exacerbate the symptoms of mothers with peripartum depression, which can impact infant development. During pregnancy, depressed women are more likely to participate in smoking or cocaine use and have poorer maternal weight gain, leading to low birth weight, maternal pre-eclampsia and premature delivery, amongst other complications. Furthermore, postpartum depression can impact maternal-infant interactions, which have been associated with negative effects on cognitive and behavioral development of infants and may have long-term effects on child development. Therefore, it is critical to detect and treat peripartum depression as early as possible. However, pregnant and postpartum women face unique barriers to seeking care. One study found that only 13.8% of women screening positive for peripartum depression, at obstetric visits, reported receiving any form of medication, psychotherapy or counseling.

Our first clinical rotation as medical students was with the obstetrics and gynecology (OBGYN) department. We expected to humanize the pathology we learned in our preclinical years and hone our clinical acumen. Neither of us imagined how much each patient would teach us. Here, we each reflect on how our respective encounters with our patients affected by peripartum depression grew our understanding of patient care.

Kristin:

“A mother was brought to gynecology triage by a concerned social worker. The patient had come in for a social work appointment, but the social worker quickly realized that the mother’s sadness was beyond circumstantial. As she was triaged, the patient tried her best to answer questions, while crying and caring for her baby. A nurse stepped in to help the mother finish changing and feeding the infant. Then, the patient tearfully shared that she was overwhelmed. Once we began the patient interview, the mother said she was constantly worried about her premature infant, especially since witnessing the baby having an apneic event. She reported that her partner recently became physically and emotionally abusive, repeatedly telling her that she should kill herself and that he no longer wanted to be with her. With this, she reported several concerning symptoms: feeling sad most of the time, having difficulty concentrating, lacking energy, wanting to sleep “forever”, and yet not sleeping more than a couple of hours for the last few weeks. Later that day, psychiatry diagnosed the patient with postpartum depression.”

Many factors can contribute to the development of postpartum depression, including, but not limited to, biology, stressful life events, prematurity of infants, low income, poor marital relationships and maternal abuse. The mother I saw was exposed to several of these factors; elements of this mother’s story are not uncommon in those affected by peripartum depression. For example, domestic violence, before, during and after pregnancy, is associated with increased odds of peripartum depression. Additionally, mothers of preterm infants have an increased risk of postpartum depression compared to those of term infants. Women experiencing postpartum depression may normalize their symptoms. Similarly, this mother normalized her sadness. Although the circumstances of her life contributed to her depression, she did not realize she was struggling beyond a normal physiologic response. The social worker’s attunement to the patient’s situation and her symptoms, led to screening and treatment of the depression. Interacting with this mother served as a reminder of the importance of exploring a patient’s concerns beyond their “chief complaint.” I find that I pay closer attention when taking the social history to have a well-rounded view of what the patient is experiencing.

Emily:

“While at the prenatal clinic, I met a pregnant woman with gestational diabetes who had been started on insulin and was asked to keep a blood glucose log at her last visit. Her log had many entries missing, but measurements recorded were in the 200s, well above what would be healthy for her and her growing baby. As the resident explored the lack of consistency with checking her blood sugars, she described difficulty getting out of bed and making meals, feeling guilty that she wasn’t taking care of herself and difficulty focusing on household chores. We discussed the diagnosis of peripartum depression, how common the diagnosis was, and how beneficial treatment could be. In response, our patient burst into tears. Once she composed herself she questioned: “How does this medication work? How long would I need to take this for? After my pregnancy, too? How would I know if it worked?” After a lengthy discussion, she verbally agreed to try the medication we recommended, but her body language remained guarded. When I returned to the room, I asked if she wanted to talk more about our recommendations from today’s visit. In the end, discussing her fears about whether psychiatric medication would change her personality was what seemed to put her most at ease. We also explored adjunctive therapies, such as journaling and mindfulness, while she waited for available psychotherapy services.” Significant barriers illustrated in this encounter included uncertainty regarding psychotropic medication safety and efficacy, in addition to stigma about psychotropic medications. Counseling this mother taught me to understand medication safety and side effect profiles from the perspective of a patient, especially when working with pregnant women. With this patient, I was struck by how much resistance there was to readily available treatments when she was clearly suffering. There is significant stigma associated with mental illness, and patients may forgo treatment to avoid label attachment. Stigma in peripartum depression patients can be exacerbated by society’s judgment of mothers’ care for their children. Finally, I learned that providing psychoeducation to patients regarding therapy in addition to medication management, can help build patient rapport. With this patient, suggesting journaling as a way to process her emotions, in addition to tracking her thoughts and moods, provided comfort as she would be able to document the effect of the medications. I hope to improve my ability to assess what stage of change a patient may be at and tailor counseling based on a patient’s concerns. In this encounter, our conversation may not have fully influenced the patient’s preconceived notions of mental health care, however, her openness to try different forms of therapy was enlightening. A multitude of factors can contribute to the development of peripartum depression. During our pre-clerkship years, most of our curriculum focused on pathophysiology and treatments of conditions. However, a couple of interactions with patients affected by peripartum depression have already illustrated that the psychosocial aspects of our patients’ lives significantly impact their medical care. These experiences taught us to consider the biological, psychological, and social components of a patient, to screen for peripartum depression, regardless of whether we are in OBGYN, pediatrics, family medicine, psychiatry or other areas of medicine. Undoubtedly, these components will help us identify other illnesses too. Thus, as we continue to grow our clinical skills, we hope to shape our ability to care for individuals, not just their conditions.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/ appi.books.9780890425596

Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. Obstetrics and Gynecology, 106(5 Pt 1), 1071–1083. https://doi.org/10.1097/01.AOG.00001 83597.31630.db

Dinwiddie, K. J., Schillerstrom, T. L., & Schillerstrom, J. E. (2018). Postpartum depression in adolescent mothers. Journal of Psychosomatic Obstetrics and Gynecology, 39(3), 168–175. https://doi.org/10.1080/0167482X.2017.1334051

Moses-Kolko, E. L., & Roth, E. K. (2004). Antepartum and postpartum depression: Healthy mom, healthy baby. Journal of the American Medical Women’s Association (1972), 59(3), 181-191.

Koire, A., Nong, Y. H., Cain, C. M., Greeley, C. S., Puryear, L. J., & continued on page 32

Van Horne, B. S. (2022). Longer wait time after identification of peripartum depression symptoms is associated with increased symptom burden at psychiatric assessment. Journal of Psychiatric Research, 152, 360-365. https://doi.org/10.1016/j.jpsychires.2022.06.046

Murray, L., & Cooper, P. J. (1997). Postpartum depression and child development. Psychological Medicine, 27(2), 253-260. https://doi.org/10.1017/s0033291796004564

Zuckerman, B., Amaro, H., Bauchner, H., & Howard, C. (1989). Depressive symptoms during pregnancy: Relationship to poor health behaviors. American Journal of Obstetrics and Gynecology, 160(5), 1107-1111. https://doi.org/10.1016/0002-9378(89)90170-1

Marcus, S. M., & Heringhausen, J. E. (2009). Depression in childbearing women: when depression complicates pregnancy. Primary Care: Clinics in Office Practice, 36(1), 151–ix. https://doi.org/ 10.1016/j.pop.2008.10.011

Howard, M. M., Mehta, N. D., & Powrie, R. (2017). Peripartum depression: Early recognition improves outcomes. Cleveland Clinic Journal of Medicine, 84(5), 388-396. https://doi.org/10.3949/ ccjm.84a.14060

Marcus, S. M., Flynn, H. A., Blow, F. C., & Barry, K. L. (2003). Depressive symptoms among pregnant women screened in obstetrics settings. Journal of Women’s Health, 12(4), 373-380. https://doi.org/ 10.1089/154099903765448880

Guintivano, J., Manuck, T., & Meltzer-Brody, S. (2018). Predictors of postpartum depression: A comprehensive review of the last decade of evidence. Clinical Obstetrics and Gynecology, 61(3), 591-603. https://doi.org/10.1097/GRF.0000000000000368

Norhayati, M. N., Nik Hazlina, N. H., Asrenee, A. R., & Wan Emilin, W. M. A. (2015). Magnitude and risk factors for postpartum symptoms: A literature review. Journal of Affective Disorders, 175, 3452. https://doi.org/10.1016/j.jad.2014.12.041

Alvarez-Segura, M., Garcia-Esteve, L., Torres, A., Plaza, A., Imaz, M. L., Hermida-Barros, L., San, L., & Burtchen, N. (2014). Are women with a history of abuse more vulnerable to perinatal depressive symptoms? A systematic review. Archives of Women’s Mental Health, 17, 343-357. https://doi.org/10.1007/s00737-014-0440-9

Howard, L. M., Oram, S., Galley, H., Trevillion, K., & Feder, G. (2013). Domestic violence and perinatal mental disorders: A systematic review and meta-analysis. PLoS Med 10(5), Article e1001452. https://doi.org/10.1371/journal.pmed.1001452

Vigod, S., Villegas, L., Dennis, C-L., Ross, L. (2010). Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: A systematic review. BJOG, 117(5), 540–550. https://doi.org/10.1111/j.1471-0528.2009.02493.x

Sword, W., Busser, D., Ganann, R., McMillan, T., & Swinton, M. (2008). Women’s Care-seeking experiences after referral for postpartum depression. Qualitative Health Research, 18(9), 1161-1173. https://doi.org/10.1177/1049732308321736

Pinto-Foltz, M. D., & Logsdon, M. C. (2008). Stigma Towards Mental Illness: A concept analysis using postpartum depression as an exemplar. Issues in Mental Health Nursing, 29(1), 21-36. https://doi.org/10.1080/01612840701748698

Emily Liu is a medical student at UT Health San Antonio Long School of Medicine, Class of 2024. She is interested in Family Medicine and Psychiatry.

Kristin Park is a medical student at UT Health San Antonio Long School of Medicine, Class of 2024. She is interested in OBGYN.

Dr. Abby O. Lozano is a psychiatrist practicing at UT Health San Antonio and University Hospital.