21.5 Postpartum Mood Disorders and Psychiatric Disorders

Risk Factors for Postpartum Depression and Anxiety

The nurse evaluates for risk factors of postpartum psychiatric disorders, such as a history of psychologic disorders before and during pregnancy, history of previous PPD or postpartum psychosis (PPP), a sick infant in the NICU, birth complications, and lack of support. Table 21.2 lists other risk factors for depression during pregnancy and postpartum.

Postpartum Psychosis

The mood disorder that occurs suddenly and can be very dangerous, with symptoms occurring within a few hours to weeks after birth, is postpartum psychosis (PPP). PPP is characterized by delusional thinking, hallucinations, and other psychotic symptoms (Alba, 2021). Other symptoms are manic elation, deep anxiety and depression, fear, and guilt (Alba, 2021). PPP is considered an emergency because paranoid thoughts can lead to homicide, infanticide, or suicide. The incidence of PPP is 0.89 to 2.6 per 1,000 births worldwide (Forde et al., 2020). When patients progress from PPD to PPP, some persons are admitted to inpatient recovery facilities to aid in safe, faster recovery.

Impact of Postpartum Depression and Anxiety on the Family

Postpartum psychiatric disorders cause the person who gave birth to feel immense loss, fear, and guilt. They have difficulty in bonding with the infant, which can have long-term behavioral and developmental effects on the newborn. Infants have breast-feeding difficulties, sleep problems, and potentially failure to thrive (Alba, 2021). Partners are also affected by postpartum psychiatric disorders and are at increased risk of developing depression and anxiety when the postpartum person experiences PPD. Partners can feel teary, stressed, sleep deprived, and experience lack of concentration and ability to support the family. The partner relationship can suffer from these disorders as well.

Maternal Morbidity and Mortality

According to the Centers for Disease Control and Prevention (CDC), the prevalence of postpartum depression in the United States ranges from 9.7 percent to 23.5 percent, with an average of 13.2 percent. (Bauman et al., 2020). Campbell et al. (2021) noted that approximately 20 percent of postpartum deaths are attributed to suicide associated with peripartum depression or psychosis. This study reveals that underlying depression is the major risk factor for increased suicidal ideation and attempts. Campbell et al. (2021) also note that Maternal Mortality Review Committees, local and state committees that review deaths associated with pregnancy and postpartum, have brought awareness to suicide. The study also found that intimate partner violence was an increased risk factor for maternal suicide and depression.

Depression Screening throughout Pregnancy and Postpartum

The American College of Obstetricians and Gynecologists (ACOG, 2018) recommends screening for perinatal depression at least once during the prenatal and postpartum periods using a validated tool. Several validated tools are available for use. The most common PPD screening tool is the Edinburgh Postnatal Depression Scale (EPDS). In pregnant and postpartum persons with current depression or anxiety, it is recommended to monitor closely for suicidal thoughts and psychosis. Health-care providers should initiate therapy and referrals for positive screens.

During the postpartum period, the nurse reviews the person’s history for current depression or anxiety, notes any antidepressants the person is taking, as well as any previous history of PPD or PPP. Nurses utilize screening tools to assess for PPD. Positive screens are reported to the health-care provider for further evaluation and treatment (Lui & Yang, 2021). The nurse also informs the postpartum person that their pediatrician will screen for PPD at their well-infant visits.

Medications throughout Pregnancy

Medications used to treat depression and some anxiety disorders usually consist of selective serotonin reuptake inhibitors (SSRIs). Yue et al. (2023) noted that SSRIs are prescribed at a lower rate for pregnant persons than for nonpregnant persons. They attributed this discrepancy to the perception of patients or health-care providers that medications for mental illness cause fetal harm. Some health-care providers will decrease the dose or wean the patient off SSRIs during pregnancy because of this perception. Studies have shown that persons who stop antidepressants during pregnancy have a 68 percent chance of major depression returning (Yue et al., 2023). A suggestion made by researchers is that health-care providers should make decisions on the use of SSRIs on an individual basis because not enough evidence is available to determine safety or harm to the fetus from antidepressant use (Besag & Vasey, 2023).

For postpartum persons, the most common medications for PPD are sertraline (Zoloft), fluoxetine (Prozac), paroxetine (Paxil), and citalopram (Celexa) (Kaufman et al., 2022). Newer medications for PPD include two neuroactive steroids: zuranolone (Zurzuave), an oral medication used for 14 days, and brexanolone (Zulresso), an IV medication given over 60 hours. All medications pass through breast milk; however, the benefits of these medications outweigh the risk for breast-feeding. Other treatments for PPD include cognitive behavioral therapy (CBT), an evidence-based therapy that helps people change their thinking patterns); acupuncture; and hormonal supplementation. Again, it is recommended for health-care providers to treat postpartum persons individually due to the lack of research on the efficacy and safety of antidepressants and their effects on breast-feeding and PPD.

Rebalancing of Hormones and Adjusting to the New Family

Rapid changes in estrogen, progesterone, and prolactin levels occur immediately after birth. This rapid change is the cause of some cases of PPD. Medications have been introduced to provide a gentler decrease in estrogen and progesterone. Adjusting to a new family dynamic is another common cause of psychosocial disturbance for postpartum persons. They must adjust to their new role, as must the other members of the family. Cognitive behavioral therapy can help the family talk through their concerns and fears to help make those adjustments easier.

Nursing Assessment and Diagnosis

Nurses assess all postpartum persons for risk factors associated with PPD and perform a risk assessment, such as the EPDS. The nurse assesses the family’s perception of the birth and any labor or birth complications. During routine assessments, the nurse evaluates for signs of PPD or lack of coping. The nurse assesses newborn bonding, partner participation, social support, and family relationships throughout the postpartum period. When the nurse recognizes signs of PPD, the nurse diagnoses ineffective coping, impaired bonding, risk for impaired parenting, and risk for self-harm. When caring for the postpartum person with a history of psychiatric disorders, it is important for the nurse to discuss suicide and other harmful behaviors. The nurse can also provide information regarding help lines, such as the Substance Abuse and Mental Health Services Administration (SAMHSA) (1-800-662-4357) or the National Maternal Mental Health Hotline, which patients can call or text 1-833-TLC-MAMA (1-833-852-6262) for a free, confidential hotline in English and Spanish for pregnant persons and new parents, 24/7.

Nursing Plan and Implementation

The nurse describes the signs and symptoms of PPD and discusses any concerning symptoms with the patient and family. The nurse explains the difference between baby blues and PPD and lists reasons why the patient and/or family should call their health-care provider (Table 21.3). The nurse encourages the family to have a plan for support when the non-birthing partner returns to work or when family members return to out-of-town locations. Social services can be consulted if the family lacks support, either emotionally or financially. The nurse provides referrals to community resources when necessary.