Study Points

Postpartum Depression

Course #96363 - $75 • 15 Hours/Credits

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Study Points

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  1. Discuss the prevalence of postpartum depression (PPD), including historical and transcultural perspectives.
  2. Identify risk factors for PPD evident prior to pregnancy, during pregnancy, and after birth.
  3. Review the effects of biochemistry, such as serotonin, estrogen and progesterone, cortisol, and thyroid, on the development of PPD.
  4. Describe the role of family history, stressful life events, and psychosocial factors in the etiology of depression.
  5. List the emotional, physical, and cognitive symptoms of postpartum blues.
  6. Discuss emotional, physical, cognitive, and behavioral symptoms of PPD.
  7. Identify severe forms of postpartum disorders, focusing on postpartum psychosis and cases of infanticide.
  8. Review the clinical assessment of PPD, including the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Depression Screening Scale (PDSS).
  9. List the effects of PPD on maternal bonding, mother-infant attachment, and a child's socioemotional and cognitive development.
  10. Describe the potential long-term effects of PPD on children.
  11. List maternal and familial complications of PPD, including marital conflict, suicide, and homicide.
  12. Discuss self-care strategies for recovery, such as nourishment, sleep, rest and relaxation, exercise, and socializing.
  13. Review the role of education in the diagnosis of and recovery from PPD.
  14. Discuss the physiologic treatment of PPD with postpartum hormone treatments.
  15. Specify pharmacologic treatment strategies, noting benefits, adverse reactions, and risks.
  16. Discuss psychosocial interventions used in the treatment of PPD.
  17. List strategies for preventing PPD, including screening, postpartum debriefing, companionship in the delivery room, psychotherapy, midwife continuity of care, and progesterone preventive treatment.
  1. Postpartum depression (PPD) occurs in approximately what proportion of new mothers?

    CATEGORIES OF POSTPARTUM MOOD DISORDERS

    PPD occurs in approximately 10% to 15% of new mothers [2,3,5]. According to multiple studies, PPD occurs at the same rate in new mothers around the world [6]. There is little evidence to suggest that any country or class of persons is not at risk for PPD. Symptoms usually occur shortly after childbirth but may occur as late as one year after delivery. PPD is a serious, long-lasting type of depression in women that can have harmful consequences for the mother and child if undetected and untreated [3].

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  2. The first documentation of PPD can be traced to

    HISTORICAL PERSPECTIVE

    Documentation of PPD can be traced to the writings of Hippocrates in the fourth century B.C.E. Hippocrates described melancholia as a state of "aversion to food, despondency, sleeplessness, irritability, and restlessness" [6]. Galen (131–201 C.E.) described melancholia as "fear and depression, discontent with life, and hatred of all people" [6]. Greco-Roman medicine recognized melancholia in the form of fear, suspicion, aggression, and suicidal thoughts. In 1436, the life story of a young mother was published and described how she felt "insane" and despaired of her life and survival after the birth of her first child [11].

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  3. Cultural perspectives influence all of the following aspects of PPD, EXCEPT:

    CULTURAL PERSPECTIVE

    Although PPD occurs worldwide, cultural differences can influence the perception of depression in women. Culture influences the expression and interpretation of symptoms, the definition of stressors, the nature of the social support system, and the relationship between healthcare provider and patient. Culture also dictates whether certain expressions of symptoms are socially acceptable. An individual's view of illness and health is also culturally bound. Displays of emotion may be encouraged in some cultures and discouraged in others [27].

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  4. All of the following are considered risk factors for PPD when they are present prior to pregnancy, EXCEPT:

    RISK FACTORS

    PPD affects women of all ages, economic statuses and racial/ethnic backgrounds. Any woman who is pregnant or has given birth can develop PPD. Whether the birth is a first child or one of multiple births has not been shown to affect the incidence of PPD. However, women with a history of depressive episodes have a greater risk for developing PPD than women with no prior history of depression. The risk of PPD is highest in women younger than 25 years of age with a prior history of mood instability. Among these women, it is estimated that 30% to 40% will have a postpartum episode of depression [30]. There are additional risk factors evident prior to pregnancy that may increase the chances of developing PPD, including [5,30,32,70,225]:

    • Past history of depression or other mental health problems

    • Family history of mood instability

    • Difficulties in relationships with the father of the baby or family, especially the woman's own mother

    • Insufficient social support or peer support group

    • Onset of depression immediately prior to conception

    • Social or financial stressors, such as money or housing problems

    • Mood disturbances, such as premenstrual syndrome (PMS)

    • Infertility treatment

    • History of abuse

    • High school or lower levels of education

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  5. Which of the following is a risk factor for PPD if present during pregnancy?

    RISK FACTORS

    Treating depression during pregnancy is a challenge because the vast majority of antidepressants cross the placenta and can have negative effects on fetal development. Psychiatrists, family practice physicians, and obstetricians may find themselves in a dilemma when diagnosing and treating depression in pregnant women. As previously noted, the onset of depression may not become evident until symptoms become severe due to the similarity of depressive symptoms and neurovegetative signs during pregnancy [33]. Although diagnosis and treatment pose a serious challenge, early recognition, diagnosis, and treatment are warranted [33]. Indication of certain risk factors that may contribute to depression during pregnancy can be helpful in a prenatal assessment. Risk factors for an onset of depression during pregnancy include [5,33,225]:

    • History of depression or substance abuse

    • Family history of mental illness

    • Lack of support from family and friends

    • Anxiety about the fetus

    • Problems with a previous pregnancy or birth

    • Marital or financial problems

    • Young maternal age

    • Single mother

    • Stressful life event, such as moving to a new area or death of family member

    • Excessive fatigue

    • Feelings of worthlessness

    • Divorce

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  6. Which of the following is NOT considered a risk factor for PPD if present after childbirth?

    RISK FACTORS

    Risk factors for PPD following the birth of a baby are similar to those present prior to conception and during pregnancy. Any combination of the following factors should be considered concerning, as it indicates a potential to develop PPD [5,32,34,225]:

    • Persisting postpartum anhedonia without sufficient social support

    • Feeling detached from the infant, not wanting to hold the baby, having negative thoughts about the baby

    • Persistent sleep disturbances

    • A fussy infant who has problems feeding or has colic

    • Signs of developing depression, such as anxiety or feeling overwhelmed

    • Birth complications or a difficult labor

    • A birth that did not live up to expectations

    • Having an infant with special needs

    • Excessive fatigue

    • Feeling overwhelmed with responsibilities of new parenthood and experiencing persistent self-doubt about mothering ability

    • Stress from changes in home and work routines, coupled with unrealistic expectations of motherhood

    • Feelings of loss: loss of identity or self-image, loss of control, loss of body image, or feeling less attractive

    • Previous episode of PPD

    • An episode of anxiety or depression during pregnancy

    • Prior experience of postpartum blues after delivery

    • History of mood changes related to normal menstrual cycle

    • Any major changes resulting in undue stress during pregnancy, such as a death in the family, unresolved conflict with her spouse, divorce, or moving from one location to another

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  7. What part of the limbic brain is believed to be involved in the fight/flight response?

    ETIOLOGY

    The areas of the brain affected by female reproductive hormones (i.e., estrogen and progesterone) are the same as those known to regulate mood stability and behavior. Therefore, it may be concluded that different hormonal circumstances can alter mood and anxiety in a woman [13]. There are several events associated with a woman's reproductive cycle that provoke mood instability in predisposed individuals, including the use of oral contraceptives, phases of the menstrual cycle, pregnancy and the postpartum period, and menopause. The vulnerability of women for mood instability bears some relationship to the fluctuation of ovarian steroids during specific phases of the reproductive cycle [36,37].

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  8. The prefrontal limbic complex plays a large role in

    ETIOLOGY

    Every significant event in life is accompanied by emotions. These events are thus emotional experiences that are "recorded" in the brain. The "emotional brain" is thought to consist of the prefrontal cortex, which is the area located directly above the eyes, and the frontal cortex. The prefrontal cortex is significantly involved with developing judgment [13]. Sichel and Driscoll refer to the connections between the limbic brain, the paralimbic brain, and the prefrontal cortex as the "prefrontal limbic complex" [13]. This complex has a large role in processing emotions, regulating mood, and storing memories. The memories of powerful life experiences, both stressful and pleasurable, are stored in this area of the brain.

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  9. Serotonin is

    ETIOLOGY

    Serotonin is a neurotransmitter known to be involved in mood and anxiety disorders. It is one of the major classes of chemical messengers known as monoamines and is associated with the induction of emotional calmness and the perception and regulation of pain, restful sleep, sexual behavior, and appetite control. A person's general level of well-being depends largely on his or her levels of serotonin [19].

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  10. Progesterone is produced primarily during

    ETIOLOGY

    Progesterone is produced during the second phase of the menstrual cycle and functions to dismantle the nerve connections established by estrogen, decreasing the number of available estrogen receptors [13]. Like estrogen, progesterone is also available in large quantities during pregnancy and drops significantly after childbirth.

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  11. Screening for thyroid dysfunction in postpartum women is important because

    ETIOLOGY

    Approximately 5% to 7% of postpartum women have abnormal thyroid levels [55,56]. Thyroid dysfunction is associated with depressed mood, and in one study, having a thyroid-stimulating hormone (TSH) level greater than 4.0 mU/L at delivery was associated with increased risk for depressive symptoms at six months postpartum [42,57,58,59]. Thyroid dysfunction has not been consistently identified in PPD; however, there may be a subgroup for whom it does play a role.

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  12. Which of the following is an aspect of family history that may predispose a woman for the development of PPD?

    ETIOLOGY

    With this in mind, certain traits are possible indicators of disturbances in brain chemistry and mood instability in some individuals [30]. Some important traits that may become evident when taking a patient's history include:

    • Family history of suicide or a preoccupation with suicidal thoughts

    • Family history of depression

    • Family history of addiction to alcohol or drugs

    • Poor judgment as indicated by inappropriate or impulsive financial, sexual, or violent behavior

    • Aggression

    • Grandiose expressions and behaviors

    • Family history of bipolar disorder

    • Unstable or chaotic lifestyles

    • Lack of empathy for others

    • Enmeshed or estranged family system

    • Family history of bouts of rage or physical abuse

    • Extremely rigid parents (disciplinarians)

    • Compulsive behavior

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  13. Approximately what percentage of those who become depressed will have another depressive episode?

    ETIOLOGY

    The brain's mood pathways can presumably be restored to normal following one depressive event without any further episodes, assuming that the depression is treated aggressively and appropriately. However, research has shown that 70% of those who become depressed will have another depressive episode [13,62].

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  14. Postpartum blues generally resolve within

    TYPES AND SEVERITY OF POSTPARTUM DISORDERS

    Postpartum blues, also referred to as "baby blues," is the most common type of postpartum mood disturbance, occurring in approximately 70% to 85% of all new mothers [3,70]. Its onset is usually shortly after birth, and it generally resolves within 10 days [2,3]. A study by Iles et al. indicated a characteristic pattern of mood changes that peaked on day 5 after delivery and declined by day 10, perhaps best described as a period of emotional upheaval following birth [71]. Incessant crying and tearfulness are the most common emotional expressions of postpartum blues [2,3].

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  15. The most common emotional expressions of postpartum blues are

    TYPES AND SEVERITY OF POSTPARTUM DISORDERS

    Postpartum blues, also referred to as "baby blues," is the most common type of postpartum mood disturbance, occurring in approximately 70% to 85% of all new mothers [3,70]. Its onset is usually shortly after birth, and it generally resolves within 10 days [2,3]. A study by Iles et al. indicated a characteristic pattern of mood changes that peaked on day 5 after delivery and declined by day 10, perhaps best described as a period of emotional upheaval following birth [71]. Incessant crying and tearfulness are the most common emotional expressions of postpartum blues [2,3].

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  16. It has been reported that 40% to 90% of PPD cases occur

    TYPES AND SEVERITY OF POSTPARTUM DISORDERS

    With an annual live birth rate of nearly 4 million in the United States each year, an estimated 600,000 women experience PPD in the United States [79,80]. Women who miscarry or whose children are stillborn are also susceptible to PPD. When this group is included in the figures, an estimated 900,000 women suffer from PPD each year [80]. Several studies have shown that PPD occurs with greater frequency in the first 3 months following childbirth than in the 6 or 12 months following [81]. Although exact percentages vary, it has been reported that between 40% to 90% of PPD cases occur within three months after childbirth. Nonetheless, women should be carefully assessed throughout the first year after childbirth, as PPD can occur up to one year postpartum [66,70].

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  17. Which of the following is NOT a cognitive symptom of PPD?

    TYPES AND SEVERITY OF POSTPARTUM DISORDERS

    When PPD affects cognitive abilities, it may present as [2,3,10,82]:

    • Thoughts of worthlessness

    • Recurrent thoughts of death or suicide

    • Difficulty concentrating

    • Memory problems

    • Difficulty thinking clearly and making decisions

    • Pervasive anxiety with excessive fear and worry

    • Excessive concern about the welfare of the child

    • Negative self-talk

    • Thoughts of harming the baby

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  18. Sleep disturbances associated with PPD are

    TYPES AND SEVERITY OF POSTPARTUM DISORDERS

    All new mothers experience a change in sleep patterns. Due to the baby's presence and the need for feedings during the night, most new mothers suffer from some degree of sleep deprivation. There is a different quality to sleep problems in women with PPD. These women have difficulty getting to sleep, have disturbed sleep, and/or wake early and are unable to go back to sleep. Insomnia is a common complaint. Even when they do sleep, it is never enough; the sleep is not refreshing. Five hours of solid sleep is often recommended; however, women with PPD are rarely able to sleep for that length of time. It is usual for new mothers to have their sleep interrupted by a crying baby, but women with PPD report that they cannot go to sleep even when the baby is settled and goes to sleep. They may lie awake worrying. Although rare, some women with PPD report sleeping too much [2,82].

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  19. Postpartum psychosis has an incidence in first-time mothers of

    TYPES AND SEVERITY OF POSTPARTUM DISORDERS

    Postpartum psychosis is an extreme condition that can occur during the postpartum period. The term "psychosis" is defined as a mental state characterized by being out of touch with reality [2]. Postpartum psychosis affects approximately 1 or 2 in 1,000 first-time mothers [3,15]. For women who experience psychosis after the birth of their first child, the risk increases by 50% for subsequent deliveries [15]. The major risk factors for postpartum psychosis are a personal history of PPD or psychosis, a family history of depression, or the presence of bipolar disorder [3,15,43,69]. One study found that nearly 10% of women hospitalized for psychiatric conditions before delivery went on to develop postpartum psychosis after their first child was born [83]. When it does occur, psychosis in a new mother constitutes a psychiatric emergency, requiring immediate treatment and, in many cases, psychiatric hospitalization.

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  20. Which of the following is considered a characteristic of postpartum psychosis?

    TYPES AND SEVERITY OF POSTPARTUM DISORDERS

    Postpartum psychosis is characterized by hallucinations, delusions, confusion, extreme agitation, inability to carry on a coherent conversation, and inability to sleep or eat [3,69]. Moods may swing from euphoria to homicidal or suicidal ideation in a short period of time without warning. The risk of suicide or infanticide requires immediate attention. Safeguards should be established to protect the mother from harming herself or her baby until psychiatric intervention becomes available [13]. Irrationality is the hallmark of postpartum psychosis, and a mother's behavior may be peculiar or described as bizarre. She may engage in frenzied activities, as though in response to stimuli not apparent to anyone other than herself [10].

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  21. Preferably, healthcare professionals should address the issue of PPD

    ASSESSMENT FOR POSTPARTUM DEPRESSION

    Data from the Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) and the U.S. Preventive Services Task Force (USPSTF) indicate that 10% to 15% of new mothers suffer from PPD, and up to 85% experience postpartum blues [92,93,94,95]. A 2017 study found a decline in PPD from 14.8% in 2004 to 9.8% in 2012 [230]. The rate of depressive disorders diagnosed at the time of delivery increased from 4.1 per 1,000 hospitalizations in 2000 to 28.7 per 1,000 hospitalizations in 2015 [231]. The CDC has therefore recommended that healthcare providers address the issue of PPD during prenatal visits, preferably during the third trimester [92]. Other sources, including the USPSTF, recommend assessing for depression throughout the prenatal period [94,96]. The USPSTF has stated that screening pregnant and postpartum women for depression may reduce depressive symptoms in women and that screening instruments can identify pregnant and postpartum women who need further evaluation and who may need treatment [94]. The screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up [94,97].

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  22. What is the most widely used screening tool available to detect PPD?

    ASSESSMENT FOR POSTPARTUM DEPRESSION

    The EPDS is limited to certain depressive symptoms and does not evaluate a woman's exhaustion, irrational irritability, or thoughts of harming her baby. These symptoms should be examined during a clinical assessment by asking specific questions relevant to these areas. Nonetheless, the EPDS is the most widely used screening tool available to detect PPD [10]. Given prenatally, the EPDS has been shown to effectively identify women at risk for PPD [102]. The EPDS may be accessed online at http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.

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  23. Which of the following statements measures the guilt/shame dimension as defined by the Postpartum Depression Screening Scale (PDSS)?

    ASSESSMENT FOR POSTPARTUM DEPRESSION

    POSTPARTUM DEPRESSION SCREENING SCALE (PDSS)

    DimensionsSample Statement
    Sleeping/eating disturbancesTossed and turned for a long time trying to fall asleep
    Anxiety/insecurityFelt really overwhelmed
    Emotional labilityCried a lot for no real reason
    Cognitive impairmentThought I was going crazy
    Loss of selfFelt like I was not normal
    Guilt/shameFelt like a failure as a mother
    Contemplating harming oneselfJust wanted to leave this world
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  24. The PDSS yields an overall severity score falling into three ranges. Which of the following is NOT a PDSS severity score?

    ASSESSMENT FOR POSTPARTUM DEPRESSION

    The test yields an overall severity score falling into three ranges:

    • Normal adjustment

    • Significant symptoms of PPD

    • Positive screen for major PPD

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  25. Mother-infant bonding dysfunction

    COMPLICATIONS OF POSTPARTUM DEPRESSION

    Bonding, in actuality, is a process of closeness, comfort, and familiarity that develops over time [19]. When the process of bonding with an infant is disrupted, it can have long-term consequences for the future relationship between mother and child. The delay in developing attachment may be unusually prolonged and delayed with a clinically depressed mother. This attachment difficulty may take different forms. The mother may not be nurturing to the infant, or she may have limited interaction with the infant. In some cases, the depressed mother may reject her baby emotionally and refuse to have anything to do with the infant. The mother may have an adverse sentiment towards the baby and handle the baby with irritability. Depressed mothers may also be outwardly angry or resentful toward the infant. Some mothers are so consumed with fears of harming their child that they avoid even touching him or her. All of these emotions and attitudes toward the child affect the process of attachment [2,109].

    Klier and Muzik describe the role of perinatal psychiatry in maternal-infant bonding issues [110]. They classify the disorders of mother-infant bonding into three groups [110]:

    • Delay, ambivalence, or loss in maternal response: Ambivalence or delay in bonding may be due to a mother's disappointment about her feelings toward the infant. She may have no feelings, feel estranged from the infant, or feel the infant is not hers.

    • Rejection (threatened or established): Rejection of the infant is expressed through strong negative feelings. The mother may dislike or hate the infant and express regret over the infant's birth. There is a notable absence of affectionate behavior, such as kissing, hugging, cooing, and cuddling. Essentially, she wants to keep the infant away from her. A mother may feel trapped by motherhood, and the infant is the source of the entrapment. She may wish the infant would be stolen, given away, or killed.

    • Pathologic anger: Pathologic anger toward the infant may be a mild form, which causes the mother distress but is controllable. Alternatively, it may be more severe, leading the mother to scream or yell at the infant or have an impulse to harm or kill the baby.

    A study of approximately 100 subjects found that mother-infant bonding disorders were present in 29% of those diagnosed with PPD [111].

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  26. Establishment of a child's social relationships is closely linked to mother-infant attachment, which can be delayed or absent in women with PPD. Success or failure of this primary developmental process depends upon all of the following, EXCEPT:

    COMPLICATIONS OF POSTPARTUM DEPRESSION

    Researchers of infant behavior have come to acknowledge that the establishment of social relationships is a primary process of development. When a child successfully accomplishes communication with others, normal development occurs. A child who does not engage the world successfully will not develop normally, regardless of the source of the failure. Success or failure depends upon three critical processes [112]:

    • The integrity and capacity of the infant's physiologic systems and central nervous system to organize and control physiologic states and behavior

    • The integrity of the infant's communicative system to express the infant's intention for action to the caretaker and the extent to which the infant succeeds

    • The caretaker's capacity to read the infant's communications appropriately and willingness to take appropriate action

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  27. Depressed mothers manifest the break in the mutual regulatory system as being either intrusive or withdrawn. Intrusive mothers often

    COMPLICATIONS OF POSTPARTUM DEPRESSION

    Studies have shown that when the mother is depressed, a break in the mutual regulatory system occurs [114]. Depressed mothers disrupt the interaction in two distinct ways: intrusiveness and withdrawal. It has been reported that intrusive mothers with PPD engaged in rough handling, spoke in an angry tone of voice, and interfered with their infants' activities. Withdrawn mothers, by contrast, were disengaged, unresponsive, and affectively flat and did little to support their infants' activities.

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  28. According to one study, children of women who were depressed three months after childbirth were at greater risk for all of the following long-term effects, EXCEPT:

    IMPACT ON SOCIOEMOTIONAL AND COGNITIVE DEVELOPMENT

    A study has been completed assessing the long-term effects on the children of mothers who were depressed three months postpartum [126]. In a community sample from two general practices in London, 149 women were given psychiatric interviews at three months after childbirth, and 89% of their children were assessed at 11 years of age. The children of women who were depressed at three months postpartum suffered attention deficit problems, difficulty with mathematics, and were more likely than other children to have special educational needs. The cognitive deficits present at 11 years of age may be a result of the quality of the infant's social environment in the first three months of life. Problems were noted in the children whether or not the mothers' depression continued beyond three months. Boys were more severely affected than girls. These effects on cognitive development were not altered by the parent's intelligence quotient (IQ) or socioeconomic status, or by the mother's later mental health problems. In this study, PPD was a risk factor for children's subsequent cognitive and behavioral problems. These findings demonstrate a long-term legacy of PPD that continues to affect children's intellectual development into adolescence [126]. Subsequent studies have reported similar findings [127,128,129].

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  29. In the United States, the greatest cause of maternal mortality in the year following childbirth is

    IMPACT ON SOCIOEMOTIONAL AND COGNITIVE DEVELOPMENT

    Statistics show that psychiatric disorders, and specifically suicide, account for 20% to 30% of all maternal deaths [130]. A review of deaths from 2006 to 2008 identified psychiatric illness as the leading cause of maternal deaths in the United Kingdom [131]. In the United States, suicide is considered the greatest cause of maternal mortality in the year following childbirth [132].

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  30. If possible, mothers should sleep a minimum of

    STRATEGIES FOR RECOVERY

    If possible, a spouse or other caregiving partner can alternate nights getting up to take care of the baby, allowing the mother to sleep at least five hours at a time. Knowing in advance that arrangements for nighttime feedings and attention to the baby can be made, mothers may ask for help without feelings of guilt or inadequacy [5]. Because women with PPD often complain of insomnia, a safe sedative may be prescribed to allow patients to obtain enough sleep.

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  31. In one study, the strongest predictor of paternal PPD was

    STRATEGIES FOR RECOVERY

    There is some evidence that men may experience a form of PPD following the birth of their child [151,152]. The strongest predictor of paternal PPD in one study was the presence of maternal depression, with symptoms tending to arise after those of the mother [152]. Therefore, fathers should also be assessed for signs and symptoms of depression in the postpartum period, particularly when their partner is depressed. Educating both parents can assist them to work together for mutual benefit and for the benefit of the baby, and may alleviate possible marital discord. In one analysis, fathers reported fewer depressive symptoms if they received support from midwives, child health nurses, and their partners (mothers) [240].

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  32. According to Dalton and Horton, the minimum effective dose of progesterone in the treatment of PPD is

    TREATMENT STRATEGIES

    One problem with the use of progesterone is that it cannot be given successfully by mouth or as a skin patch, but must be administered by injection or vaginal or rectal suppository. According to Dalton and Horton, 400-mg suppositories administered twice daily are the minimum effective dose [10]. However, empirical data has not found progesterone to be effective in the treatment of PPD and it may intensify depressive symptoms in some patients [157].

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  33. Symptoms and signs of serotonin syndrome include all of the following, EXCEPT:

    TREATMENT STRATEGIES

    The U.S. Food and Drug Administration (FDA) has alerted healthcare professionals and the public regarding a potentially life-threatening condition called serotonin syndrome. Serotonin syndrome, or serotonin toxicity, results from an excess of serotonergic activity in the central nervous system. It is seen only rarely in postpartum women, usually when multiple antidepressants, such as TCAs, MAOIs, St. John's wort, or opioids are combined. Serotonin syndrome is a medical emergency that requires immediate treatment. Symptoms and signs of this syndrome include [167,168]:

    • Restlessness

    • Tachycardia

    • Diarrhea

    • Nausea

    • Vomiting

    • Overactive reflexes

    • Loss of coordination

    • Hallucinations

    • Hyperthermia

    • Hypertension

    • Coma

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  34. For women taking a selective serotonin reuptake inhibitor (SSRI), the best time to breastfeed is

    TREATMENT STRATEGIES

    Studies have shown that SSRIs peak in the breast milk seven to nine hours after maternal dosing. The highest concentrations are found in the hindmilk [163,176,232]. The best time to nurse is one hour before taking the SSRIs. If a mother must breastfeed during the peak concentration, she may nurse for a brief period and discard the hindmilk, which will help to reduce the amount of medication the baby receives [177].

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  35. Possible side effects of feeding and sleep disorders have been reported in breastfeeding infants of mothers taking

    TREATMENT STRATEGIES

    Fluoxetine produces the highest proportion of infant levels (22%), elevated more than 10% above the average maternal level, and fluoxetine has a longer half-life than either sertraline or paroxetine [166]. Two case reports of nursing infants whose mothers were taking fluoxetine related instances of increased irritability, colic, increased crying, decreased sleep, increased vomiting, and watery stools [176]. The long-term neurobehavioral development of infants exposed to fluoxetine has not been investigated. It is a drug "of concern" and should be used with caution in nursing mothers [163].

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  36. Tricyclic antidepressants are contraindicated in patients

    TREATMENT STRATEGIES

    There are a variety of factors that contraindicate the use of TCAs. TCAs should not be prescribed to anyone with a history of heart disease, as they may cause cardiovascular problems. There have also been cases of TCAs triggering manic episodes in patients with a personal or family history of bipolar disorder [190,191]. It is also important not to prescribe TCAs with any of the following medications or other items, as there are risks of dangerous interactions [189]:

    • Bicarbonate of soda

    • Oral contraceptives

    • Some sleeping medications

    • Some anticoagulants

    • Aspirin

    • Other antidepressants

    • Diabetes medications

    • Antiarrhythmic medications

    • Mood stabilizers and anticonvulsants

    • Pain medications and anesthetics

    • Blood pressure medications

    • Stimulants

    • Weight loss drugs

    • Diuretics

    • Thyroid supplements

    • Tobacco

    • Antihistamines

    • Alcohol

    • Antibiotics

    • Sedatives and tranquilizers

    • Estrogen

    • Disulfiram

    • Antipsychotic drugs

    • Antifungal agents

    • Ephedrine

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  37. As part of the treatment of PPD, group therapy is

    TREATMENT STRATEGIES

    The advantages of group therapy are that it is cost effective, reduces isolation, and offers support and empathy from others with similar problems. The disadvantages are that there is no one-on-one interaction between the therapist and each individual, and the group is not specifically tailored to meet each individual's particular needs [34]. Additionally, some mothers' childcare responsibilities may interfere with their ability to attend and participate in group therapy sessions [199]. A feasibility study on the effects of telecare therapy (i.e., a combination of cognitive-behavioral therapy, relaxation techniques, and problem-solving strategies) indicated that this may be an effective treatment option for women with PPD who are unable to attend group therapy sessions or support groups [200].

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  38. Which of the following is a barrier to effective and efficient postpartum care in the United States?

    PREVENTIVE STRATEGIES

    Prevention of PPD is of utmost interest to researchers and clinicians, and it is clear that preventing severe depression would have clear benefits for mothers and children. Two barriers to effective and efficient postpartum care in the United States have been identified: the lack of parity between insurance coverage for mental and physical illnesses decreases access to care, and the current model of postpartum care fails to incorporate screening and follow-up. In developing a prevention model in the United States, these concerns should be taken into account. The types of prevention strategies employed should be determined by the risk factors with which a woman presents. Early detection and treatment are keys to a full recovery [207]. Healthcare professionals involved in childbirth education are in an excellent position to offer pregnant women anticipatory information about postpartum complications, including PPD [124].

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  39. In addition to screening for PPD during pregnancy, it is recommended that clinicians screen postpartum women at

    PREVENTIVE STRATEGIES

    An effort to place greater emphasis on identifying any previous psychiatric illness in pregnant women and their families, combined with the continuous observation of the psychologic well-being of women during pregnancy, will enable potential sufferers of PPD to receive treatment at the earliest possible stage. In addition to screening for PPD during pregnancy, screening at six weeks, three months, and six months postpartum should become routine. It remains the primary responsibility of physicians treating women of childbearing age to ensure that all healthcare professionals involved in prenatal care have a full knowledge of the devastating effects of PPD and actively work to detect women at risk as early as possible [10]. As noted, the EPDS is the most accepted and widely used screening tool available today and takes only a few minutes to administer. Having a standardized mechanism of screening available for all pregnant women should become the standard of care. Without a formal assessment, most depressive symptoms will remain undetected by primary care health professionals [201].

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  40. Several studies regarding the efficacy of natural progesterone for the prevention of PPD found that prevention of symptom recurrence was

    PREVENTIVE STRATEGIES

    If utilized, it is advised that, upon completion of labor, the patient is given 100 mg of progesterone by injection daily for seven days, followed by a 400 mg suppository twice daily until the return of menstruation. The dosage of suppositories may be increased if the mother experiences a return of mild early symptoms. Each woman should also be equipped with information about the symptoms of PPD [10]. At the end of two months, if menstruation has not begun and no symptoms appear, the number of suppositories may be reduced and then discontinued. If menstruation has begun and symptoms appear, progesterone should be given from day 14 of the cycle until the next menstruation. Natural progesterone should only be given in the prescribed method of administration. Studies have been conducted on progesterone preventive treatment in 1985, 1989, 1994, and 1995 [10]. In these studies, the prevention of symptom recurrence was 90% to 92% successful.

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