NUR 7642 Module 6 Postpartum Depression Case: EPDS Screening, Interpersonal Therapy and New Medicines Example

Seven Weeks After the Birth: Screening and Treating Postpartum Depression in a Breastfeeding First-Time Mother of 31

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7642: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Adult Population, Part B

Mentor Name

Month Day, Year

Seven Weeks After the Birth: Screening and Treating Postpartum Depression in a Breastfeeding First-Time Mother of 31

The Visit

Natalie, an invented patient, is 31 and works as a paralegal in Hackensack. Her son was born seven weeks ago after a long labor that ended in an emergency cesarean. At her pediatrician's well-baby visit, she cried while the nurse weighed the baby, and a screening questionnaire was positive. She was referred the same day.

She describes feeling flat and tearful most of the day for about five weeks. She takes no pleasure in her son and feels guilty about it. She sleeps poorly even when the baby sleeps, has little appetite and cannot concentrate on simple tasks. She worries constantly that she is a bad mother and that something will happen to him. Her husband works long hours, and her own mother lives in Florida. She breastfeeds and wants to continue. She had a period of depression in college that resolved without treatment.

Her delivery is part of her distress. She had planned an unmedicated birth, labored for twenty hours and then was rushed to surgery when the baby's heart rate dropped. She remembers little of the first hour after he was born and feels she "failed the first test." She has replayed the delivery many nights since. Her obstetrician's six-week visit focused on her incision, and no one asked about her mood until the pediatric screen.

Screening

Cox et al. (1987) built the Edinburgh scale from pilot interviews, cut it to ten self-rated items and tested it on 84 mothers against Goldberg's standardized psychiatric interview. It showed satisfactory sensitivity and specificity, tracked changes in depression over time and took about five minutes. Its items avoid symptoms such as tiredness and poor sleep that are common in all new mothers. Cut points of 10 to 13 are widely used in practice.

Natalie scores 17. Item 10, about thoughts of harming herself, is answered "hardly ever." The interview confirms major depression with onset after delivery, meeting criteria with peripartum onset.

Risk to Mother and Baby

When she says her husband and son might do better without her, the nurse practitioner asks more; she has no plan or intent and says her son is her reason to keep going. She is asked, gently and plainly, whether she has had thoughts of harming the baby. She has had brief frightening images of dropping him on the stairs, which horrify her and lead her to avoid carrying him on the stairs. These are intrusive thoughts she rejects, common in postpartum depression and anxiety, and very different from the beliefs of postpartum psychosis. She has no confusion, hallucinations or bizarre beliefs, and no history of bipolar disorder. Her thyroid tests, since postpartum thyroiditis can mimic depression, and her blood count, after blood loss at delivery, are checked.

Interpersonal Psychotherapy

O'Hara et al. (2000) randomly assigned 120 women with postpartum major depression to twelve weeks of interpersonal psychotherapy or a waiting list. Depression scores on a clinician scale fell from 19.4 to 8.3 with therapy compared with 19.8 to 16.8 on the waiting list, and 37.5 percent recovered on that scale compared with 13.7 percent. Social functioning also improved more with therapy. The therapy focuses on role transitions and relationships, which fit the changes a new baby brings.

For Natalie, interpersonal therapy addresses her role change from a busy professional to a mother at home, her disappointment about the birth, the strain with her husband over night feedings and her isolation from her mother. Sessions are held by video during the baby's morning nap. Her husband attends the third session to plan one full night of sleep for her each weekend, with him giving pumped milk.

The birth itself is given room in therapy. Natalie writes down what she remembers and what she was told, and her obstetrician, with her consent, reviews the record with her at a separate visit, which fills in the missing hour. Hearing that the team acted to protect her son, and that nothing she did caused the emergency, eases some of the guilt she has carried since the delivery.

Medicine While Breastfeeding

Because her score is in the moderately severe range, medicine is also offered. Sertraline is chosen because it passes into breast milk in very low amounts and has been widely used by breastfeeding mothers with few reported effects in infants. It starts at a low dose and rises after a week. Her pediatrician is told, with her consent, and asked to note the baby's feeding, sleep and weight at regular visits.

Meltzer-Brody et al. (2018) reported two phase 3 trials of brexanolone, an intravenous form of a natural hormone given as a continuous 60-hour infusion, in women with moderate to severe postpartum depression. In the first trial, of 138 women, depression scores fell by 19.5 and 17.7 points at the two doses compared with 14.0 on placebo by 60 hours, and the second trial also favored brexanolone. Sleepiness and loss of consciousness can occur, so it is given only in a monitored setting.

Support at Home

Postpartum Support International's local group meets by video on Thursdays. Her mother plans a two-week visit. Her husband takes one night feeding each weeknight. She is reminded that sleep protects her recovery and that the intrusive images are a symptom, not a sign she will harm her son.

Conclusion

Natalie has postpartum depression with intrusive thoughts and passive thoughts of death, found with the Edinburgh scale and confirmed at interview, with no signs of psychosis. Interpersonal psychotherapy, supported by a trial in postpartum women, addresses her role change and isolation, and sertraline is started with attention to breastfeeding. Brexanolone is understood as a fast hospital option for severe illness. Her EPDS, sleep and safety will be checked every two weeks, and her pediatrician will follow the baby's growth.

References

Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150(6), 782-786. https://doi.org/10.1192/bjp.150.6.782

Meltzer-Brody, S., Colquhoun, H., Riesenberg, R., Epperson, C. N., Deligiannidis, K. M., Rubinow, D. R., Li, H., Sankoh, A. J., Clemson, C., Schacterle, A., Jonas, J., & Kanes, S. (2018). Brexanolone injection in post-partum depression: Two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. The Lancet, 392(10152), 1058-1070. https://doi.org/10.1016/S0140-6736(18)31551-4

O'Hara, M. W., Stuart, S., Gorman, L. L., & Wenzel, A. (2000). Efficacy of interpersonal psychotherapy for postpartum depression. Archives of General Psychiatry, 57(11), 1039-1045. https://doi.org/10.1001/archpsyc.57.11.1039