UNDETECTED, UNTREATED
Most cases of postpartum depression remain undiagnosed despite being more prevalent than other disorders affecting childbearing women
By Arabella Cabading, Contributing Writer
"Distraught ma kills baby."
This item hogged the headline of a local tabloid several months ago. It was about a young mother who, in a fit of depression, drowned her newborn baby in a bucketful of water.
In the past few years, there had been similar reports in the media about women hurting their own children or setting fire to their home weeks after giving birth.
In all likelihood, these women may have been suffering from postpartum depression-a serious medical condition characterized by various emotional, behavioral, and physical changes that develop after childbirth. Its cause is still the subject of research but it is linked to the sudden drop in hormonal levels after delivery as well as with some social and psychological changes that come with having a baby.
One in 10 women experience this type of depression after giving birth but most people do not even know it exists.
What is PPD?
Postpartum blues or "baby blues," the mildest and most common type of this disorder, afflicts 50 to 75 percent of mothers. It is marked by crying spells, anxiety, and despondency that may last for a few hours or a couple of weeks at the most following delivery. Symptoms usually subside without treatment on the 10th day after childbirth.
Major postpartum depression (PPD) refers to a far more severe condition characterized by frequent crying bouts, fatigue, anxiety, irritability, guilt feelings, and the inability to look after the baby and even one's self. Around 10 percent of new moms go through this for several weeks or months after delivery. If left untreated, the depression could worsen and linger for about a year.
At the end of the spectrum is postpartum psychosis (PPP), which hits only one in 1,000 women who have just given birth. Manifestations include disorientation, hyperactivity, insomnia, severe agitation, rapid speech, paranoia, delusions, and hallucination. These with PPP must be promptly admitted for treatment, as they tend to be suicidal and may harm the baby as well.
Undiagnosed, underdiagnosed
In an article on OBGyn.net, Dr. Kathryn Leopold, an assistant professor at the Albany Medical College in New York, and Dr. Lauren Zoschnick, a clinical instructor at the University of Michigan, point out that although PPD is more common in the United States than gestational diabetes, preeclampsia, and preterm delivery, it has not been given enough attention in contemporary medical literature and clinical practice.
In like manner, psychiatrist Roderick Ramos cites the utter lack of statistics on the prevalence of PPD in the country despite the fact that it is more prevalent than many disorders plaguing childbearing women.
PPD is "considerably underdiagnosed," wrote Dr. C. Neill Epperson, chief of the behavioral-gynecology program at Yale University School of Medicine, in an article published online by the American Family of Physicians.
Perhaps "undiagnosed" is more apt since most PPD patients remain untreated.
Ramos agrees that many depressed women are not brought to health-care providers for treatment.
"Women with depression are more tolerated than men and are not likely to be brought for treatment, especially those who are not employed outside the home. Most men are working and are more likely to be admitted for treatment so they could become productive again. Also men tend to be more violent than women," he explains, adding that while most cases eventually recover without treatment, recovery time would have been much shorter had they been treated promptly.
Perhaps another barrier to seeking treatment for this condition is its prohibitive cost.
"Treatment does not come cheap. Medications cost around PhP100 a day, which is expensive for most patients," Ramos notes.
Depending on the severity of the case, those who have been diagnosed with PPD are usually given antidepressants, alone or in combination with psychotherapy.
Left unchecked, PPD may eventually take its toll on the entire family, putting a heavy burden on the husband and leaving the children vulnerable to conduct and attention disorders and even "social and cognitive delays" (DA Seehusen, et al.). Studies also show that children of women diagnosed with PPD may have difficulty relating with their mother and are prone to behavioral problems both at home and in school.
Is it PPD, panic disorder, or a thyroid problem?
Epperson believes that PPD is also largely misdiagnosed and mistaken for other conditions such as panic disorder, thyroid deficiency, and even anemia.
Panic disorder and postpartum anxiety have similar symptoms that include intense fear and anxiety, rapid breathing, accelerated heart rate, hot or cold flashes, chest pain, shaking, or dizziness (Postpartum Depression Fact Sheet, NWHIC).
After giving birth, women may experience a sharp decrease in thyroid levels which may bring about mood swings, sleeplessness, fatigue, agitation, and anxiety similar to those seen in depression cases.
Women who lose a lot of blood during childbirth may experience fatigue due to anemia and this may be misconstrued as a sign of depression.
Epperson thus insists that these conditions be ruled out before making a definitive diagnosis.
No training, no screening
He also believes that since most cases of PPD in the US are treated by primary-care physicians, they must be skilled in detecting mood disorders in women.
This writer interviewed four practicing family physicians to see if they are adequately trained to diagnose PPD cases and if there is any systematic screening for PPD at their level. One works at a government health center while the other three are from different private hospitals. All have not had any training and have never screened postpartum patients for PPD in their entire medical practice.
Dr. Teresita Cueva, a primary-health-care provider at the health center in San Fernan-do, La Union, admits they do not have any formal training in PPD diagnosis and management and neither do they screen postpartum patients for PPD at all. "Follow-up checkup of postpartum patients is usually done by our midwives who do not have any training in PPD," she says.
Dr. Hildegunda Santos, a senior family physician at the Lorma Hospital, says she may have come across cases of postpartum blues before but these were few and far between. "If ever I had cases which I suspect to be postpartum depression, I did counseling and then referred them to a psychiatrist," she relates.
"I've never encountered a single case of postpartum depression in my 35 years of active medical practice. That's perhaps because I usually refer ob cases to obstetricians," says Dr. Virgilio Cabading, a family physician based in La Union.
Dr. Eva Marie Madayag of the La Union Medical and Diagnostic Hospital says she does the same. "I don't handle ob cases; I refer them right away to an ob-gyne."
But Ramos, a consultant at the same hospital, says even ob-gynes are not very keen on PPD. "Some even mistake its symptoms for hormonal imbalance," he says. He, however, disclosed that he himself has handled only a few postpartum patients-about one in 50 cases-and mostly referrals from ob-gynes.
A simple diagnostic tool
According to Leopold and Zoschnick, this type of depression can be easily diagnosed and treated by the primary-care physician who is "willing to take the most basic measures." Apparently, they were referring to the Edinburgh Postnatal Depression Scale (EDPS), a simple diagnostic tool consisting of 10 short statements that most women could answer without difficulty in five minutes.
A study at a community postnatal-care site in Minnesota found that routine administration of EDPS increased the rate of PPD diagnosis from 3.7 percent to 10.7 percent.
But even in the United States where doctors have more opportunities for training in PPD management and where screening tools are readily available, screening is not a universal practice and PPD is just as well considered an underdiagnosed disorder.
Results of a survey among members of the Washington Academy of Family Physicians showed that while most doctors polled exert effort to screen for depression among their postnatal patients, a significant number (five percent of those who deal with routine postpartum gynecologic checkups and 15 percent of those who handle well-child visits) never did any PPD screening at all.
Only 30.6 percent of those who screened said they are using a validated screening tool and of these, only 18 percent are using a tool specially designed for PPD screening.
A call for intervention
Clearly a lot of interventions need to be done to significantly improve the diagnosis and treatment of PPD in the country.
Family physicians and obstetrician-gynecologists alike need to undergo training in PPD management to avoid underdiagnosis and misdiagnosis. Efforts should also be exerted to make PPD an integral part of the family-residency curriculum.
Routine screening of postpartum patients using a validated tool like the EDPS should be instituted in both public and private settings to ensure that women with depression as well as those at risk could be given appropriate intervention. For public-health facilities, translating the questions and statements in the screening tool would make it better understood by non-English readers.
Finally, as in any medical condition, there is always a need to educate the patients and their family members by making posters, flyers, and other information materials on PPD available in conspicuous places inside clinics and hospitals.
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