Table 1.
Keys to the diagnosis of postpartum depression
| 1. Establish diagnostic threshold for major depressive disorder (MDD): five or more of 9 signs or symptoms (a thru i below) persisting for ≥2 weeks, with at least one being an essential diagnostic feature (a or b below): | ||
| • Essential diagnostic features: | ||
| a. Persisting depressed mood | Have you been feeling depressed or down most of the day, nearly every day? How long has it lasted? | |
| b. Persisting anhedonia | Have you lost interest or pleasure in things that you usually enjoy? How long has it lasted? | |
| • Additional diagnostic signs and symptoms: | ||
| c. Changes in appetite or body weight (increase or decrease) | Has your appetite changed from normal during the time you have been feeling depressed? Have you started eating (more/less) than usual? Did you intend to (gain/lose) weight? | |
| d. Persisting insomnia or hypersomnia | Have you noticed any changes in the amount of quality of your sleep during the time you have been feeling depressed? How many yours a night compared to normal? Do you have problems falling asleep, staying asleep, or waking up too early (or a combination of these)? | |
| e. Changes in psychomotor activity (agitated or slowed) | Have you been so fidgety or restless that you couldn’t sit still? Have others noticed (what did they say)? Have you or others noticed that you have been talking or moving more slowly than usual? | |
| f. Persisting fatigue or energy loss | Have you felt tired or run down all the time, or nearly every day, during the time you have been feeling depressed? | |
| g. Feelings of worthlessness or excessive guilt | Have you been feeling worthless on a daily or near-daily basis during the time you have been feeling depressed? Have you been feeling more guilty than usual about mistakes, things you have done, or even things you have not done? | |
| h. Persisting problems concentrating or making decisions | Has it been harder for you than normal to maintain your focus or think through things during the time you have been feeling depressed? Has it been harder to make everyday decisions? | |
| i. Recurring thoughts of death or suicide | Have you been thinking a lot about death, or that you might be better off dead? Have you been thinking of hurting yourself? Have you done anything to hurt yourself? Are you having these thoughts now? | |
| 2. Establish peripartum onset of depression according to updated (DSM-5 criteria): | ||
| Previously adopted (DSM-IV-TR) diagnostic criteria | Updated (DSM-5) diagnostic criteria | |
| • MDD with post-partum onset: onset of depressive symptoms within 4 weeks postpartum. | • MDD with peripartum onset: onset of depressive symptoms during pregnancy or within 4 weeks postpartum. | |
| 3. Link depressive signs and symptoms with maternal dysfunction: “Has your depression caused you to have any problems with…” | ||
| • …your ability to take care of yourself, eat right, or maintain your hygiene? | • …your relationships, such as family, friends, or your partner? …maintaining connection with others in your life? | |
| • …your ability to take care of your baby, or feel close to (him/her)? | • …your ability to work, study, or keep up around the house? | |
| • …your ability to breastfeed (for those who choose to)? | • …your ability to deal effectively with life stressors and solve problems (specify the most important problems)? | |
| 4. Estimate the severity of symptoms based on their level of impact on daily functioning: | ||
| Mild: mild disability, but can function normally with considerable extra effort. | Moderate: clear maternal dysfunction; cannot be overcome with extra effort, but not incapacitated. | Severe: inability to function in most if not all important life domains; suicidal thinking is often prominent. |
| Otherwise, the 10th item on the PHQ-9 (“…how difficult have these problems made it for you…”) can be used to estimate depressive symptom severity: Mild = PHQ-9 item 10 “somewhat difficult” Moderate = PHQ-9 item 10 “very difficult” Severe = PHQ-9 item 10 “extremely difficult” | ||
| 5. Rule out postpartum thyroid disorders, anemia, and other medical illnesses that overlap with depression. | ||
| • Consider: complete blood count (TSH), thyroid stimulating hormone (TSH), vitamin D level, vitamin B12 and folate level, and other laboratory screening tests as otherwise indicated. | ||
| 6. Rule out psychiatric disorders that overlap with major depression (as discussed in the article text). | ||
| • Screening questions for past mania or hypomania can include: | Have you ever had a period of time in your life when you were not feeling like yourself because your mood and your energy were unusually high, and the speed of your thoughts were unusually fast? Did others tell you or become concerned that you were behaving abnormally or talking too fast? | |
| 7. Screen for common comorbid psychiatric disorders (e.g., anxiety and substance use disorders, as discussed in article text), and associated illness features of potential concern (obsessions thoughts of harming the infant, psychotic signs and symptoms). | ||
| • Screening questions for pathological anxiety can include: | Do you also have problems with anxiety, panic attacks, or worry that you can’t seem to control? Do these problems interfere with your ability to function in any way? How often does this occur? | |
| • Screening questions for alcohol abuse can include: | How often do you have a drink? Has your drinking caused problems for you? Have you felt you ever needed to cut back or stop drinking because of this? Have you taken a drink to try to reduce your depression? Has anyone expressed concern about your drinking? | |
| • Screening questions for other substance abuse can include: | Have you ever used street drugs? Have you ever gotten hooked on a prescribed medicine or taken one to get high (specify name of medicine[s])? Have you ever taken more than you were supposed to? | |
| • Screening questions for obsessive thinking (not necessarily a diagnosis of obsessive-compulsive disorder) can include: | Have you ever been disturbed by thoughts that made no sense, but kept coming back, even when you tried to ignore them? Like being contaminated by germs, or hurting someone else even if you really didn’t want to? Some women even have thoughts about harming their baby that really upset them because they don’t want to do that—have you also had these kinds of thoughts? | |
| • Screening questions for psychosis can include: | Do you ever hear things that others can’t, such as noises or voices of other people? Do you ever hear voices that tell you to harm yourself or your baby? Have you been concerned about people talking about you, spying on you, or planning to do bad things to you? Do you receive special messages from the TV, radio, newspaper or the internet? Have you felt that you were especially important or powerful in some way, or had special powers to do things that others can’t do? Have you been concerned that you have terrible disease or physical problem doctors can’t explain or fix? Have you been concerned that you have committed some sort of crime or done something so terrible that you need to be punished? | |