WISCONSIN MEDICAL JOURNAL

Postpartum Depression:
Identification, Screening, and Treatment
Jennifer Perfetti, MA, LPC; Roseanne Clark, PhD; Capri-Mara Fillmore, MD, MPH

ABSTRACT whereas standard screening tools are more effective in

Depression during the postpartum period is a signifi- identification of this often debilitating condition.
cant public health concern, affecting 8%-15% of Promoting awareness and providing information about
women and resulting in considerable morbidity for postpartum depression, along with the implementation
women, and their infants and families. Risk, prevalence, of a screening and referral protocol, can reduce the high
and distinguishing features of postpartum mood disor- rates of under-diagnosis associated with this disorder
ders are provided. Anxiety and depression frequently and can help women obtain the evaluation and treat-
co-occur, suggesting symptoms of anxiety should also ment necessary at this critical time.
be attended to when screening for postpartum depres- The spectrum of postpartum mood disorders in-
sion. Recommendations include the use of a brief, valid cludes the postpartum blues, postpartum depression,
screening instrument as a routine clinical practice and and postpartum psychosis, disorders that have a good
the unique role of the obstetrician/gynecologist, pedia- deal of overlap in symptomotology but also have
trician, and family practice physician in identification unique differentiating features. The postpartum blues is
and referral. A summary of evidence-based treatment the most common of these disorders, affecting 50%-
options for postpartum depression, along with current 80% of new mothers, with onset occurring within the
information about psychotropic medication, is pro- first 10 days postpartum. Symptoms include emotional
vided to assist in risk-benefit analyses and decision lability, anxiety, fatigue, insomnia, anger, sadness, and
making with patients. irritability. These symptoms are transient and generally
resolve within 10-14 days postpartum.
INTRODUCTION Postpartum psychosis is a more severe, but rarer,
The screening and identification of depression during disorder affecting approximately 1 out of 1000 new
pregnancy and the postpartum period offers physicians mothers. Onset can range from 1 day postpartum
a unique opportunity to impact family health and func- throughout the first postpartum year. Symptoms of
tioning at the earliest point possible. Postpartum de- postpartum psychosis include agitation, racing
pression represents a significant public health concern, thoughts, rapid speech, insomnia, hallucinations, para-
affecting 8%-15% of women and resulting in consider- noia, thoughts of suicide and infanticide, along with the
able morbidity for women, their infants, and families.1 standard depressive symptoms.
Notably, rates of postpartum depression are over twice
as high for women living in poverty, ranging from SYMPTOMS, ONSET, AND PREVALENCE
22%-34% in this population.2-5 Postpartum depression shares the DSM-IV criteria for
The societal portrayal of an idealized motherhood, Major Depressive Disorder (see Table 1).6 Although the
along with the stigma of mental illness, makes this a DSM specifies onset within 4 weeks of the birth, clini-
problem that is frequently underreported by new cians and researchers generally agree that onset can
mothers who attempt to hide their distress and struggle occur any time within the first year after birth.1 A re-
alone. Physicians often depend on clinical observation, view of studies looking at onset has found that between
40%-67% of cases begin within the first 3 months
Ms Perfetti and Dr Clark are with the University of Wisconsin postpartum.1 Without treatment, 30%-70% of these
Medical School. Doctor Fillmore is with the Medical College of women may experience depression for a year or
Wisconsin. Please address correspondence to Roseanne Clark, longer,7,8 with individual depressive episodes lasting
PhD, Department of Psychiatry, University of Wisconsin Medical
School, 6001 Research Park Blvd, Madison, WI 53719; phone anywhere from 4 weeks to more than 6 months.9
608.263.6067; fax 608.262.0265; e-mail rclark@wisc.edu. In identifying symptoms of postpartum depression,

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it is of note that anxiety may be a prominent feature in Table 1. DSM-IV Criteria for Postpartum Depression6
a womans presentation. DiNardo and Barlow found
Five or more of the following symptoms, including:
that up to 66% of depressed individuals have a co-mor-
bid anxiety disorder.10 Symptoms of anxiety disorders Depressed mood

may be more apparent to womens physicians than de- Markedly diminished interest or pleasure in activities
pressive symptoms and should not be overlooked or at- Appetite disturbance
tributed to more general new mother anxiety. Rather, Sleep disturbance
these symptoms need to be listened to carefully and Physical agitation or psychomotor retardation
comprehensively assessed as they may be part of the Fatigue, decreased energy
presentation of postpartum depression. Feelings of worthlessness or inappropriate guilt
Though an exact cause is unknown, there are many Decreased concentration or inability to make decisions
factors that increase a womans risk for developing Recurrent thoughts of death or suicidal ideation
postpartum depression. The greatest associated factor is
Symptoms present most of the day, nearly every day, for 2
the presence of symptoms of depression or anxiety weeks and must represent a change from previous functioning
during pregnancy. Additionally, women with an indi- causing significant distress or impairment.
vidual or family history of a depressive episode or anx-
iety disorder are at higher risk for postpartum depres-
sion. Another factor that may influence whether a exhibiting behavior that is either sad and withdrawn or
woman develops postpartum depression is the amount intrusive.15 Mothers who are depressed also tend to re-
of social support she receives, including how emotion- flect their infants negative feeling states more often
ally supported and satisfied she is feeling in her rela- than they respond to or mirror their smiles or positive
tionship with her spouse or partner. Finally, recurrent social initiatives.14
life stressors comprise a global category that can impact Disturbances in the quality of a mothers affective
risk for postpartum depression; examples of potential and behavioral interactions with her infant can have
stressors include physical health problems in the multiple implications for the infant during this early
mother or infant, a significant loss in the past year, or period when the capacities for emotional regulation
serious financial difficulties. and healthy attachment relationships are developing.
Postpartum depression is truly a systemic issue, af- More infants and young children of mothers with post-
fecting a womans functioning and sense of well being partum depression have been found to have delays in
as well as her relationship with her infant and family. cognitive and motor development.9,15 In addition, stud-
Postpartum depression can impact a womans capacity ies have shown more insecure attachments, with disor-
for parenting, which in turn can decrease her sense of ganized-disoriented attachments being 3-4 times more
competence in the mothering role, potentially exacer- likely in children of depressed mothers compared to
bating her depression.11 Depressive symptoms, includ- children whose mothers were not depressed.16-18
ing lack of energy and capacity to concentrate, may im- Infants of women with postpartum depression have
pair a womans ability to be involved in her childs been observed to display more negative affect both
physical care and play, and may increase her level of ir- with their mother and other non-depressed adults, in-
ritability and self-preoccupation, resulting in an inabil- cluding increased sober, sad, and/or flat affect and more
ity to meet her childs normal needs for attention.12,13 In protest behaviors.19 In addition, these infants tend to
addition, mothers who are depressed may experience a exhibit more regulation difficulties, gaze aversion, less
lack of affection toward their child, which can lead to eye contact, fewer vocalizations, delayed language de-
feelings of guilt or worthlessness, and they may often velopment, lower activity level, and more limited ex-
feel anxious about doing psychological or physical ploration of the environment than infants of non-de-
harm toward their child. pressed mothers.16,19,20 Postpartum depression can have a
It is important to note that the fact that a mother is bi-directional effect on mother-infant interactions.21,22
depressed alone does not indicate how well she cares The mothers depressed affect can induce a depressed
for her baby.14 Some mothers are able to respond sensi- state in the infant, and in turn the infants subsequent
tively and consistently to their infants, despite their de- distress and unresponsiveness are likely to maintain
pressive symptoms. Nonetheless, more women experi- and perhaps increase the severity of the mothers de-
encing postpartum depression have been found to pression.
display an impaired ability to care for their infant, often Maternal sensitivity, however, is a moderator and has

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 WISCONSIN MEDICAL JOURNAL
been found to reduce the consequences of chronic ma- who is teething, not recognizing her symptoms as signs
ternal depression on the child.23 The father, or other of a more serious disorder. Additionally, the woman
caregiver, can provide contingently responsive care and may experience irritability and anxiety as her primary
cognitive, emotional, and physical stimulation that can symptoms, and may not recognize that these features
mediate a lack of maternal responsiveness. The infants can be related to postpartum depression.
temperament can have the effect of either exacerbating The prenatal period is an ideal time to begin screen-
symptoms of depression or minimizing them, depend- ing for depression and to provide early intervention.
ing on characteristics such as sleep patterns, frequency Research has shown that as many as 23% of women
of crying, or being easy going and socially reinforc- who are diagnosed with postpartum depression had
ing.24,25 Length of maternity leave may also mediate out- symptoms that started in pregnancy.31 If identified dur-
comes for mothers with postpartum depression. Clark ing pregnancy, these women could be referred for treat-
et al26 found that mothers who had shorter maternity ment to a mental health provider focused on decreasing
leaves expressed more negative affect and behavior in depressive symptoms and could be involved, along
interactions with their infants compared to mothers with their partners, in planning supportive interven-
with longer maternity leaves. Women who reported tions for the postpartum period, which can help to re-
more depressive symptoms but had longer leaves dis- duce the risk of a postpartum depressive episode.
played more positive affect, sensitivity, and responsive- The hospital post-delivery assessment is often too
ness with their infant, thus longer leaves may provide a early to make a diagnosis of postpartum depression,
buffering effect for depressed women. but does provide an opportunity to screen for risk fac-
tors associated with postpartum depression. A recent
SCREENING METHODS Canadian study32 found that an Edinburgh Postnatal
The severity of the impact of postpartum depression on Depression Scale (EPDS) screen at 2 to 3 days postpar-
maternal and infant functioning makes screening and tum predicted postpartum depression at 4 to 6 weeks.
identification of this disorder an important priority. When the 10 point cutoff was used, sensitivity was 64%
Many medical professionals rely on their clinical im- and specificity was 85% (using the repeat screen as the
pressions alone to determine whether a woman appears standard). The 6-week Ob/Gyn follow-up visit pro-
depressed, but several studies have shown that up to vides an optimal opportunity for screening, as it occurs
50% of mothers with major depression are missed by well after the 2-week point that distinguishes the post-
primary care physicians when screening instruments partum blues from postpartum depression and is an ap-
are not used.27-29 Depressed mood during pregnancy has pointment that is specifically focused on the womans
been associated with poor attendance to prenatal clin- well-being.
ics, substance misuse, low birth-weight infants, and Pediatric and family practice well-baby visits are op-
pre-term delivery.30 Both during pregnancy and in the portune times to screen for postpartum depression.
postpartum period, depression can interfere with Pediatricians and family practice physicians are a
healthy relationships and can even be life threatening if mothers most frequent health contact during the pe-
the woman is having thoughts of suicide or infanticide. riod of greatest risk for postpartum depression, putting
There are many reasons that a woman who is expe- them in a unique position to assess women and to pro-
riencing postpartum depression might not be open vide early intervention, education, and appropriate re-
about her symptoms with her provider. Stigma regard- ferrals.
ing mental illness may cause a woman to feel shame and Screening for postpartum depression is a brief best-
therefore underreport her symptoms, or may cause her practice intervention that can be implemented easily in
to fear that if she acknowledges symptoms of depres- a clinic setting. Upon arrival to their appointment,
sion or difficulty parenting that others may think she is women can be given the screening instrument to com-
an unfit parent and her child may be taken away from plete in the waiting room while they wait for their
her. scheduled appointment. The screening tool can be
Another reason that standardized screening is im- quickly scored by nurses, medical assistants, or non-
portant is that the woman herself may be unaware of medical staff. Results of the screening instrument
the seriousness of her symptoms. She or those around should be reviewed with the patient by the medical
her may minimize her symptoms or attribute them provider during that appointment.
solely to factors such as feeling overwhelmed with the If the woman endorses a significant number of
demands of a new baby, a lack of sleep, or an infant symptoms, which puts her score above the cutoff im-

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plying a clinical level of depressive symptoms, a referral Table 2. Edinburgh Postnatal Depression Scale (EPDS)34
should be made for a comprehensive mental health
Circle the number for each statement, which best describes
evaluation. This should be conducted by a mental
how often you felt or behaved this way in the past 7 days
health professional with specialized experience in the
I have been able to laugh and see the funny side of things.
evaluation and treatment of postpartum depression. It
0 As much as I always could
may be prudent to obtain the womans permission to 1 Not quite so much now
call the referral source and have them contact her, as the 2 Definitely not so much now
symptoms of depression create a high probability that 3 Not at all
if just handed a phone number or brochure, the woman Things have been getting on top of me.
will not follow through with the referral or treatment. 3 Yes, most of the time I have not been able to cope at all
If the woman endorses an item indicating suicidal 2 Yes, sometimes I have not been coping as well as usual
1 No, most of the time I have coped quite well
ideation or reports thoughts of harming her infant, the
0 No, I have been coping as well as ever
referral should be made immediately while the woman
I have looked forward with enjoyment to things.
is still in the office with the provider, making sure that
0 As much as I ever did
she can be seen the same day as an outpatient or, if 1 Rather less than I used to
safety is a concern, evaluated in an emergency room. 2 Definitely less than I used to
It is also important to assess the womans level of so- 3 Hardly at all
cial support, provide family members with informa- I have felt so unhappy that I have had difficulty sleeping.
tion, and involve them in referral and safety planning.33 3 Yes, most of the time
Assessing a womans perceived level of support is criti- 2 Yes, sometimes
cal, along with helping to identify ways to add to or en- 1 Not very often
0 No, not at all
hance her support system. Involving family members
often helps the woman to feel more connected, and as- I have blamed myself unnecessarily when things went wrong.
0 No not at all
sists the family members in decreasing their sense of
1 Hardly ever
bewilderment or helplessness. 2 Yes, sometimes
3 Yes, very often
SCREENING TOOLS I have felt sad and miserable.
One of the most common self-report screening instru- 3 Yes, most of the time
ments used for postpartum depression is the Edinburgh 2 Yes, quite often
Postnatal Depression Scale (EPDS).34 (See Table 2.) 1 Not very often
0 No, not at all
Generally the same screeners used for postpartum
women are utilized for pregnancy depression screen- I have been anxious or worried for no good reason.
3 Yes, quite a lot
ing. The EPDS has been used internationally and trans-
2 Yes, sometimes
lated into more than 20 languages.35 Due to findings 1 No, not much
that women with postpartum depression often have a 0 No, not at all
high level of co-morbid anxiety, it is important that a I have been so unhappy that I have been crying
postpartum depression screener also include anxiety 3 Yes, most of the time
items. The EPDS has a cutoff of 10 to signify probable 2 Yes, quite often
depression, and has been shown to have a sensitivity of 1 Only occasionally
95% and specificity of 93%.36 A multinational review 0 No, never

of the EPDS validation (with DMS-based standard) in I felt scared or panicky for no very good reason.
18 postpartum studies with cutoffs between 8.5-12 3 Yes, quite a lot
2 Yes, sometimes
points found specificity 49%-100% and sensitivity
1 No, not much
65%-100%.37 0 No, not at all
Given the high prevalence rates of postpartum de-
The thought of harming myself has occurred to me.
pression, the potential for dire consequences to mother 3 Yes, quite often
and infant and the high likelihood for successful treat- 2 Sometimes
ment, the importance of screening for postpartum de- 1 Hardly
pression is evident. In Bright Futures in Practice: 0 Never
Mental Health Volume 1, the American Academy of Total = ________
Pediatrics encourages screening for postpartum mood

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 WISCONSIN MEDICAL JOURNAL
Table 3. Considerations when Prescribing Any Medication to sion that recognizes the need to treat mother-infant and
Lactating Women38 family relationships as well as the depressive symp-
1. Determine whether the medication is necessary. toms.43 Women participating in the mother-infant ther-
2. Choose the safest medication available, with preferential apy were found to have fewer depressive symptoms
attention to one that:39 when compared to those in a waiting list control group.
is safe when administered directly to infants In addition, mothers in mother-infant therapy per-
has a low milk:plasma ratio
ceived their babies as more adaptable and reinforcing
has a short half-life
has a high molecular weight
and displayed increased levels of positive affect, sensi-
has high protein binding in maternal serum tivity, and responsiveness in interactions with their in-
is ionized in maternal plasma fants. This family-focused group model serves to re-
is less lipophilic duce social isolation as well as depressive symptoms,
3. Consult with the infants pediatrician when possible. increase coping skills, and improve interpersonal rela-
4. If there is possibility that the drug may present risk to the
tionships.
infant, monitoring of infant serum drug levels is recom-
mended. Psychotropic medication is another common tool in
5. Minimize drug exposure by advising the mother to take the the treatment of postpartum depression. There is con-
medication just after breastfeeding or just before the infant cern, however, on the part of both patients and health
is due for a long sleep period. care providers regarding the implications of psy-
chotropic medication for pregnant and breastfeeding
disorders.40 Both the Association of Family Physicians women and their infants. The recommended practice is
and College of Obstetricians and Gynecologists Web to conduct an individualized and careful risk-benefit
sites have pages advising patients and answering ques- analysis with each woman in deciding whether medica-
tions about the symptoms and treatment of postpartum tion is the best option for both her and her baby.46 This
depression. individualized risk-benefit analysis should weigh the
The US Preventive Services Task Force uses evi- potential effects of medication on the fetus or infant
dence-based data in determining screening recommen- with the impact that the depression may have on the
dations for the country, and in its 2002 report recom- womans functioning and capacity for parenting.
mended the routine screening of adults for depression Thoughts of harm to self or infant should also be as-
in primary care.41 Depression during the postpartum sessed and factored into this decision. The FDA has as-
period was not specifically addressed, but given that the signed risk categories for medications for depression
consequences of this depressive disorder impact both and bipolar disorder during pregnancy that can be con-
maternal and infant functioning, the recommended sidered when conducting this risk-benefit analysis.47,48
routine primary care screening of adults for depression For additional guidelines regarding prescribing medica-
should clearly include pregnant and postpartum tion to women who are breastfeeding see Table 3.38,39
women. When prescribing antidepressant medication, it is im-
perative to follow up to assess whether the prescribed
TREATMENT dose has been effective, possible side effects, and
The most robust risk factor for infant/child outcome is whether her functioning has improved.
the chronicity of the mothers depression. Chronic de- For many breastfeeding mothers a non-pharmaco-
pressive symptoms are related to greater delays in lan- logical treatment, such as psychotherapy, may be the
guage and cognitive development as well as behavioral first order of treatment. Several studies have shown
difficulties at school entry.23 This makes it imperative psychotherapy to be equally effective to medication in
that a woman with postpartum depression get treat- the treatment of major depression of moderate sever-
ment as early as possible to both ameliorate depressive ity.49,50 Antonuccio reviewed studies comparing the effi-
symptoms and reduce the likelihood of recurrent de- cacy of medication and psychotherapy, and, in summa-
pressive episodes. rizing his analysis, states medications result in
Research has shown several types of psychotherapy relatively poorer compliance than psychotherapy, have
to be effective specific to the treatment of postpartum a higher dropout rate, and result in as much as a 60%
depression: Individual Interpersonal Psychotherapy, non-response rate with some patient populations.
Cognitive Behavioral Therapy, and group or family Psychotherapy can teach skills to help prevent depres-
therapy.42-45 Clark et al have described a mother-infant sion, making such treatment an attractive, cost-effective
therapy group (M-ITG) model for postpartum depres- alternative to drug treatments.49 In the NIMH

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 WISCONSIN MEDICAL JOURNAL
Treatment of Depression Collaborative Research Table 4. State and National Resources
Program, a multi-site randomized controlled clinical
Postpartum Depression Treatment Program and Information
trial, Elkin and colleagues compared the effectiveness
Center-UW Medical School Department of Psychiatry
of cognitive behavioral psychotherapy, IPT, 608.263.5000. For information about participation at no cost
imipramine with clinical management and placebo with in a NIMH funded psychotherapy clinical trial, go to:
clinical management, all of which were associated with www.psychiatry.wisc.edu/ppd
a significant reduction in depressive symptoms.50 Both
Maternal and Child Health Hotline800.722.2295
imiprimine with clinical management and IPT were
equally and significantly more effective than the other WI Association for Perinatal Carewww.perinatalweb.org
treatments in treating severely depressed patients. A Postpartum Support International(PSI)-Wisconsin Chapter
potential exception to use of psychotherapy alone is a www.postpartum.net
woman who is suicidal, has thoughts of harming her in-
Depression After Delivery, Inc. (DAD)800.944.4773.
fant, or is so depressed that she cannot function in www.depressionafterdelivery.com
safely caring for her child. In this case, medication may
DHFS/Bureau of Community Mental HealthInformational
be a necessary intervention. (For various treatment re-
packets and videotapes on postpartum depression for health-
sources, see Table 4.) care professionals. 608.267.7792

ANTI-DEPRESSANT MEDICATION DHFS/Bureau of Family and Community HealthMore Than

Just the Blues pamphlets for consumers on postpartum de-
AND LACTATION
pression, available in English, Spanish and Hmong,
A recently published comprehensive review of the 608.266.8178
available data regarding antidepressant levels in nursing
infants offers several guidelines for differentiating be-
tween antidepressant medications commonly pre- Bupropion.53 However, Weissman et al state that
scribed to breastfeeding women.51 This study con- though their research does not currently show that ele-
cluded that infants exposed through breastfeeding to vated levels have consequences for infants, a conserva-
nortriptyline, paroxetine, or sertraline seemed unlikely tive approach may be to prescribe only medications
to develop detectable or elevated plasma levels. that do not appear in infants plasma.51 This approach is
Conversely, infants exposed to fluoxetine, and poten- especially prudent when factoring in the possibility
tially those exposed to Citalopram, appear to be at that plasma levels may not accurately predict the bio-
higher risk of developing elevated levels, especially if chemical effect of an antidepressant on the rapidly de-
they had also been exposed prenatally or if levels are veloping brain.
high in the breast milk.
The American Academy of Pediatrics considers SUMMARY
lithium to be contraindicated during lactation. Lithium, With a prevalence rate of 8%-15%, depression during
Valproate, Carbamazepine, Venlafaxine, Citalopram, the postpartum period is a significant public health
Nefazodone, Sertraline, Fluoxetine, and Doxepin have problem, affecting the functioning of women, their in-
been found present in infant serum or have been associ- fants and families. Ob/Gyns, Pediatricians, and Family
ated with side-effects in infants.52 All of the infant Practice physicians are in a unique position to identify,
serum detectable medications have had adverse effects refer, and help these women access an appropriate men-
reported, except Sertraline (which was undetectable in tal health evaluation and treatment. Standardized
most reports) and Venlafaxine. The only reported case screening for postpartum depression is a best-practice
of negative effect of Citalopram was an infant with procedure and should be incorporated into the routine
colic and uneasy sleep.46,47,52 Pediatricians and Family clinical protocol of medical providers working with
Practice physicians should know if mothers who are women during pregnancy and in the first year after
breastfeeding are taking antidepressant medication and birth. Psychotherapy focused on interpersonal rela-
should monitor levels in the infants serum as well as tionships and family functioning is a particularly effec-
the infants behavior.38 tive treatment for postpartum depression. When con-
A review by Chaudron indicates several antidepres- sidering the use of psychotropic medication to treat
sant medications are undetectable in breastfed infants depression during pregnancy and lactation, a risk-ben-
serum: Amitriptyline, Nortriptyline, Clomipramine, efit analysis related to the welfare of both the woman
Desipramine, Paroxetine, Fluvoxamine and and her baby should be standard practice. Integrating a

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focus on a womans mental health needs during preg- for mothers and infants: a relational approach. Madison, WI:
Author; 1994.
nancy and after the birth of a baby into routine clinical
20. Field T, Guy L, Umbel V. Infants responses to mothers imi-
care will have a positive impact on the well-being of tative behaviors. Inf Mental Hlth J. 1985;6(1):40-44.
women, their infants and families. 21. Field T, Walden T. Production and discrimination of facial ex-
pressions by preschool children. Child Dev. 1982;
53(5):1299-1311.
REFERENCES 22. Meltzoff A. Foundations for developing a concept of self: the
1. OHara MW. The nature of postpartum depressive disorders. role of imitation in relating self to other and the value of so-
In Cooper PJ, Murray L, eds. Postpartum Depression and cial mirroring, social modeling, and self practice in infancy. In
Child Development. New York: Guilford Press; 1997:3-31. Cicchetti D, Beeghly M, eds. Self inTransition: Infancy to
2. Hobfoll SE, Ritter C, Lavin J, Hulsizer MR, Cameron RP. Childhood. Chicago: University of Chicago Press; 1990:139-
Depression prevalence and incidence among inner-city 164.
pregnant and postpartum women. J Consult Clin Psychol. 23. National Institute of Child Health and Human Development
1995;63(3):445-453. Early Child Care Research Network. Chronicity of maternal
3. Patel V, Rodrigues M, DeSouza N. Gender, poverty, and depressive symptoms, maternal sensitivity, and child func-
postnatal depression: a study of mothers in Goa, India. Am J tioning at 36 months. Dev Psychol. 1999;35:1297-1310.
Psychiatry. 2002;159:43-47. 24. Kendall-Tackett K. Postpartum Depression and the
4. Chaudron LH. Postpartum depression: what pediatricians Breastfeeding Mother. La Leche League International, Unit 8
need to know. Pediatr Rev. 2003;24(5):154-161. Lactation Consultant Series Two. No1468-19. 2004.
5 Foss GF. Maternal sensitivity, posttraumatic stress, and ac- 25. Kitzinger S. The Crying Baby. New York: Penguin Press;
culturation in Vietnamese and Hmong mothers. Am J 1990.
Maternal Child Nursing. 2001;26:257-263. 26. Clark R, Hyde J, Essex M, Klein M. Length of maternity
6. American Psychiatric Association. Diagnostic and Statistical leave and quality of mother-infant interactions. Child Dev.
Manual of Mental Disorders, Fourth Edition, Text Revision. 1997;68(2):364-383.
Washington, DC: American Psychiatric Association; 2000. 27. Gale S, Harlow BL. Postpartum mood disorders: a review of
7. Cutrona C. Nonpsychotic postpartum depression: a review of clinical and epidemiological factors. J Psychosom Obstet
recent research. Clin Psychol Rev. 1982;2:487-503. Gynaecol. 2003;24(4):257-266.
8. OHara MW. Postpartum mental disorders. In Sciarra JJ, ed. 28. Steiner M. Postnatal depression: a few simple questions.
Gynecology and Obstetrics (Vol. 6). Philadelphia: Harper & Fam Pract. 2002;19(5):469-470.
Row; 1991:1-17. 29. Cooper PJ, Murray L. Postnatal depression. Br Med J.
9. Murray L, Cooper PJ. The role of infant and maternal factors 1998;316(7148):1884-1886.
in postpartum depression, mother-infant interactions, and in- 30. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort
fant outcomes. In Cooper PJ, Murray L, eds. Postpartum study of depressed mood during pregnancy and after child-
Depression and Child Development. New York: Guildford birth. Br Med J. 2001;323:257-260.
Press; 1997:111-135. 31. Watson JP, Elliott SA, Rugg AJ, Brough DI. Psychiatric disor-
10. DiNardo P, Barlow D. Syndrome and symptom co-occur- der in pregnancy and the first postnatal year. Br J
rence in the anxiety disorders. In J Maser, CR Cloninger, Psychiatry. 1984;144:453-462.
eds. Comorbidity of Mood and Anxiety Disorders. 32. Teissedre F, Chabrol H. Detecting women at risk for postna-
Washington, DC: American Psychiatric Press; 1990:205-230. tal depression using the Edinburgh Postnatal Depression
11. Clark R, Keller AD, Fedderly SS, Paulson AW. Treating the Scale at 2 to 3 days postpartum. Can J Psychiatry.
relationships affected by postpartum depression: a group 2004;49(1):51-54.
therapy model. Zero to Three. 1993;13(5):16-23. 33. Wisconsin Association for Perinatal Care. Position
12. Weissman MM, Olfson M. Depression in women: implica- Statement: Screening for Prenatal and Postpartum
tions for health care research. Science. 1995;269:799-801. Depression (WAPCPS9:1/03/3000). January 2003.
13. Weissman MM, Psykel ES, Klerman GL. The depressed Available at www.perinatalweb.org/association/pdf_docs/
woman as a mother. Soc Psychol. 1972;7:98-108. MoreThanBlues.pdf. Accessed October 26, 2004.
14. Clark R, Fenichel E. Mothers, babies and depression: ques- 34. Cox JL, Holden JM, Sagovsky R. Detection of postnatal de-
tions and answers. Zero to Three. 2001;22(1):48-50. pression: development of the 10-item Edinburgh Postnatal
15. Cohn JF, Campbell SB, Matias R, Hopkins J. Face-to-face Depression Scale. Br J Psychiatry. 1987;150:782-786.
interactions of postpartum depressed and nondepressed 35. Cox J, Holden J. Perinatal Mental Health: A guide to the
mother-infant pairs at two months. Dev Psychol. Edinburgh Postnatal Depression Scale. The Royal College
1990;26(1):15-23. of Psychiatrists; 2003.
16. Lyons-Ruth K, Zoll D, Connell D, Grunebaum HU. The de- 36. Harris B, Huckle P, Thomas R, Johns S, Fung H. The use of
pressed mother and her one-year old infant:environment, in- rating scales to identify post-natal depression. Br J
teraction, attachment and infant development. Maternal Psychiatry. 1989;154:813-7.
Depression Infant Disturbances. 1986;34:61-82. 37. Eberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S,
17. Bakermans-Kranenburg MJ, van IJzendoorn MH, Juffer F. Samuelsen SO. Review of validation studies of the
Less is more: meta-analyses of sensitivity and attachment Edinburgh Postnatal Depression Scale. Acta Psychiatr
interventions in early childhood. Psychol Bull. Scand. 2001;104(4):243-249.
2003;129(2):195-215. 38. American Academy of Pediatrics, Committee on Drugs. The
18. Teti DM, Gelfand DM, Messinger DS. Maternal depression transfer of drugs and other chemicals into human milk.
and the quality of early attachment: An examination of in- Pediatrics. 2001;108(3):776-789.
fants, preschoolers, and their mothers. Dev Psychol. 39. Della-Giustina K, Chow, G. Medications in pregnancy and
1995;31(3):364-376. lactation. Emerg Med Clin North Am. 2003;21(3):585-613.
19. Clark R. Manual for postpartum depression group therapy

62 Wisconsin Medical Journal 2004 Volume 103, No. 6

 WISCONSIN MEDICAL JOURNAL
40. American Academy of Pediatrics. Bright Futures in Practice: 48. US Food and Drug Administration, Center for Drug
Mental Health Volume 1. Chicago: Author; 2002. Evaluation and Research, Anti-Infective Drugs Advisory
41. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for Committee, Pediatrics Subcommittee. Summary Minutes of
depression in adults: a summary of the evidence for the US the Pediatrics Subcommittee of the Anti-Infective Drugs
Preventive Services Task Force. Ann Intern Med. Advisory Committee. June 9, 2004. Available at
2002;136(10):765-776. www.fda.gov/ohrms/dockets/ac/04/minutes/2004-
42. OHara M, Stuart S, Gorman L, Wenzel A. Efficacy of inter- 4050M1.doc. Accessed October 26, 2004.
personal psychotherapy for postpartum depression. Arch 49. Antonuccio DO, Danton WG, DeNelsky GY. Psychotherapy
Gen Psychiatry. 2000;57:1039-1045. versus medication for depression: challenging the conven-
43. Clark R, Tluczek A, Wenzel A. Psychotherapy for postpartum tional wisdom with data. Prof Psychol-Res Pr. 1995;26(6):
depression: a preliminary report. Am J Orthopsychiatry. 574-585.
2003;73(4):441-454. 50. Elkin I, Shea MT, Watkins JT, et al. National Institute of
44. Holden JM, Sagovsky R, Cox JL. Counseling in a general Mental Health treatment of depression collaborative pro-
practice setting: controlled study of health visitor intervention gram: general effectiveness of treatment. Arch Gen
in treatment of postnatal depression. Br Med J. Psychiatry. 1989; 63:841-847.
1989;298:223-226. 51. Weissman A, Levy B, Hartz A, et al. Pooled analysis of anti-
45. Cooper PJ, Murray L. The impact of psychological treatment depressant levels in lactating mothers, breast milk, and nurs-
of postpartum depression on maternal mood and infant de- ing infants. Am J Psychiatry. 2004;161:1066-1078.
velopment. In: Cooper PJ, Murray L, eds. Postpartum 52. American Academy of Pediatrics, Committee on Drugs. Use
Depression and Child Development. New York: Guilford of psychoactive medication during pregnancy and possible
Press; 1997:201-220. effects on the fetus and newborn. Pediatrics. 2000;105(4 Pt
46. Wisner KL, Zarin DA, Holmboe ES, et al. Risk-benefit deci- 1):880-887.
sion making for treatment of depression during pregnancy. 53. Chaudron LH. Postpartum depression: what pediatricians
Am J Psychiatry. 2000;157(12):1933-1940. need to know. Pediatr Rev. 2003;24(5):154-161.
47. Marcus SM, Barry KL, Flynn HA, Tandon R, Greden JF.
Treatment guidelines for depression in pregnancy. Int J
Gynaecol Obstet. 2001;72(1):61-70.

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