Journal Article Annotations
2022, 1st Quarter
Annotations by Jyoti Sachdeva MD
The postpartum period is a period of high vulnerability for first episode or relapse of bipolar disorder (BD), and a significant number of women with postpartum affective instability turn out to have bipolar illness. The Edinburgh Postnatal Depression Scale (EPDS) is commonly used for screening of postpartum mood symptoms but does not capture bipolar disorder; many postpartum women are erroneously diagnosed with unipolar depression (UD) and treated with antidepressant monotherapy. The authors compared the symptoms of 728 postpartum women with UD and 272 postpartum women with BD. These women were identified by a score > 10 on EPDS between 4-6 weeks postpartum and diagnosis later established by full evaluation via Structured clinical interview for DSM-4 (SCID) via phone interview or home-visit. Compared with women with UD, women with BD were more likely to report a history of abuse; a comorbid anxiety disorder; and certain somatic and psychiatric symptoms such as compulsions, paranoia, and suicidal thoughts. The authors proposed a sub-score of Hamilton depression symptoms to identify women at risk of having BD and report its sensitivity to be 52% and specificity to be 82%.
Strength and weaknesses:
This is the first study to differentiate clinical presentation of BD from UD in the postpartum population. Because only women who screened positive on EPDS were included, the study likely missed women who were exhibiting manic or hypomanic symptoms. Inclusion in diagnostic analyses was also affected by exclusion of women who did not have to access to a telephone or stable housing, or who refused SCID evaluation.
These findings help C-L psychiatrists accurately identify women with bipolar disorder in the postpartum setting and thereby initiate appropriate therapy.
This is a prospective longitudinal observational cohort study—Optimizing Medication Management for Mothers with Depression (OPTI‐MOM)—of 88 pregnant women. Questions addressed through the study were, What is the symptom course of SSRI‐treated women across childbearing? Do depressive and anxiety symptoms vary together? Do symptoms increase after birth? Women completed assessments every 4 weeks from study entry until delivery and until 6-14 weeks postpartum.Inclusion criteria were -18 to 45 years of age, singleton pregnancy less than 18 weeks, a lifetime DSM‐IV diagnosis of MDD (any subtype), and current treatment with sertraline, fluoxetine, citalopram, or escitalopram with the intent to continue through pregnancy and postpartum. Exclusions were defined as bipolar or psychotic illness, ongoing substance use, Edinburgh postnatal depression scale (EDPS) >25 and response of 3 on self-harm thoughts question on EPDS. The scales used were the EPDS, Quick Inventory of Depressive Symptoms (QIDS), Generalized Anxiety Disorder Scale, (GAD‐7) and Patient‐Reported Outcomes Measurement Information System Global Health (PROMIS‐GH). Upon study entry, most participants were not in remission despite maintenance drug treatment. Three relatively stable depression trajectories emerged: Minimal (EPDS<5), Mild (EPDS=5), and Subthreshold (EPDS 8 or higher). Anxiety varied across 4 trajectories; 2 of the 4 anxiety trajectories were stable, including Asymptomatic and Minimal, while the third, termed Breakthrough, was ascending with increasing symptoms. A fourth anxiety trajectory, described as Mild, had descending symptoms.
Strength and weaknesses:
This study’s strengths included obtaining novel data from monthly self‐report symptom assessments through pregnancy and after birth in women who were treated with an SSRI at enrollment. The sample was limited: all were SSRI‐treated women and predominantly white, married, and educated women. Secondly, because only SSRI-treated women were included, symptom trajectories for women treated with other classes of antidepressants were not described.
This study demonstrates that the treatment goal to achieve full resolution of maternal depression and anxiety symptoms remains a clinical challenge despite maintenance pharmacological treatment. In the setting of incomplete treatment, the fetus remains exposed to both the illness and the drug. The majority of women also had coexisting anxiety symptoms, which underscores the importance of screening for and treating anxiety in this population. These findings also encourage psychiatrists to implement measures of anxiety and depression throughout the perinatal period to monitor for residual symptoms.