Postpartum depression: development of a standardized protocol in pediatric primary care settings
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Postpartum psychiatric disorders include the postpartum blues (PBs), postpartum depression (PPD), and postpartum psychosis (PP). The focus of this thesis will be on PPD. PPD is a commonly unrecognized mood disorder affecting up to 15% of women. Of women with PPD, half may go untreated. Untreated PPD has shown significant potential for adverse effects in both mother and child. The reproductive hormone model attributes PPD to the rapid hormone changes following removal of the placenta at delivery. This is especially true of the withdrawal of the reproductive hormones estrogen and progesterone. A true causal pathway or causal factor in PPD depression, however, is yet to be established. Several factors must be taken into account when considering risk. These risk factors include women of low socioeconomic status (SES), women with a history of depression, women with a higher reported average of recent life stressors, women with neurotic and/or shy personalities, and women who experience past and/or present obstetric complications. Currently, the Edinburgh Postpartum Depression Scale (EPDS), the Postpartum Depression Screening Scale (PDSS), the Patient Health Questionnaire-9 (PHQ-9), as well as several other screening tools are used in clinical practice to diagnose PPD. Each screening tool utilizes its own unique method to obtain depression scores from patients. The EPDS is most commonly used, yet, no statistically significant difference has been found between the use of one screening tool over the other. PPD screening tools are seen across OB/GYN practices, family practices, health centers, and pediatric practices. Routine well-child visits represent the most regular contact that mothers have with the healthcare system postpartum, making pediatric primary care practices ideal settings for PPD screening and management. PPD management within primary care primarily involves non-pharmacological interventions such as counseling, psychoeducation, motivating help seeking, encouraging social support, and referring to others as needed. On the other hand, medication management is integrated into the stepped care treatment approach, which screens for and treats PPD in a step-wise fashion tailored to a woman’s risk assessment and responsiveness to treatment. Treatments for PPD have varying success. They may include selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SSNRIs), gamma aminobutyric acid receptor A positive allosteric modulators (GABAA receptor PAMs), norepinephrine and dopamine reuptake inhibitors (NDRIs), estrogen therapy, omega-3 polyunsaturated fatty acid supplementation (n-3 PUFA), cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), electroconvulsive therapy (ECT), and bright light therapy (BLT). More statistical evidence currently exists on the use of pharmacological and psychotherapeutic treatments, and less on the ECT and BLT clinical treatments. Mothers deciding on which treatment to pursue should consider the potential for psychotropic and estrogen medications to pass into their breast milk and onto their infant. New mothers should also outweigh the risks and benefits of pursuing pharmacological treatment rather than letting their depression go untreated. By conducting a thorough literature review, this thesis serves the purpose of identifying the most effective treatments to be integrated with a modified stepped care pathway, thereby creating a standardized PPD protocol that can be used across pediatric primary care practices. The aim of standardization of protocol using specific treatments in a modified stepped care approach is to effectively detect maternal PPD, minimize the potential for harm to mother and infant, as well as improve the consistency of care provided to mothers diagnosed with PPD. Implemented correctly, the protocol should show increased use of validated PPD screening tools such as the EDPS in practices managing care for postpartum mothers and/or infants up to the age of one, followed by risk assessment, and then treatment escalated from psychotherapy to antidepressants if required.