The new Diagnostic Statistical Manual — the DSM-V — has officially been released by the American Psychiatric Association. So what does it say about postpartum depression?
Not what I thought it would. In the DSM-IV, to diagnose Major Depressive Disorder with Postpartum Onset, symptoms needed to appear in the first 4-6 weeks. As you know, many moms don’t recognize postpartum depression symptoms until much later in the first year. It’s my belief that this has led to moms going to see their docs and being told they couldn’t have PPD because it was too late.
My understanding was that in the new DSM-V, that would change. To make the qualification for Major Depressive Disorder with Postpartum Onset, symptoms could appear any time in the first four months. Others have said the discussion leading up to revisions of the DSM also revolved around extending it to as far as six months.
Yet yesterday I got a copy of the new pages (pg. 186 and 187) and it still says 4 weeks. So frustrating.
With peripartum onset: This specifier can be applied to the current or, if full criteria are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.
The DSM does now recognize antenatal depression, since the listing has changed from a postpartum onset specifier to a peripartum onset specifier.
The DSM-V also offers a detailed note on using the Major Depressive Disorder with Peripartum Onset diagnosis:
Note: Mood episodes can have their onset either during pregnancy or postpartum. Although the estimates differ according to the period of follow-up after delivery, between 3% and 6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery.
What the heck made them decide on that low number? 3%? Y’all must be kidding. It’s more like 10-15%.
Fifty percent of “postpartum” major depressive episodes actually begin prior to delivery. Thus, these episodes are referred to collectively as peripartum episodes. Women with peripartum major depressive episodes often have severe anxiety and even panic attacks.
Good. Great points to have added about antenatal depression and about the anxious nature of postpartum depression.
Prospective studies have demonstrated that mood and anxiety symptoms during pregnancy, as well as the “baby blues,” increase the risk for a postpartum major depressive episode.
Peripartum-onset mood episodes can present either with or without psychotic features. Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but psychotic symptoms can also occur in severe postpartum mood episodes without such specific delusions or hallucinations.
Postpartum mood (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1000 deliveries and may be more common in primiparous women.
Primiparous means first pregnancy.
The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of depressive or bipolar disorder (especially bipolar 1 disorder) and those with a family history of bipolar disorders.
Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30 and 50%. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a fluctuating level of awareness or attention. The postpartum period is unique with respect to the degree of neuroendocrine alterations and psychosocial adjustments, the potential impact of breast-feeding on treatment planning, and the long-term implications of a history of postpartum mood disorder on subsequent family planning.
There you have it. What do you think about the new postpartum depression listing?
Photo credit and citation: American Psychiatric Association
I think it doesn’t capture the full range of the symptoms/onset of PPD. It is a huge shame that the onset hasn’t changed, and that the prevalence rates are so wildly inaccurate. Also, the “baby blues” are experienced by and estimated 75% of women, so how does that translate to a higher risk of PPD?
Who was in charge of this? they failed. Makes for an interesting section in my thesis though…..
“What the heck made them decide on that low number? 3%? Y’all must be kidding. It’s more like 10-15%.”
I don’t think anyone “decided” on the 3% to 6%, I believe that is what research found.
Um, no. NOPE. Sorry.
Instead of the sarcastic reply, why not post the research that disputes this figure? I thought it was that low as well, so now I’m curious.
On another note, I personally think PPD is WAY over diagnosed, but that’s just an opinion. PPD symptoms just happen to be the same symptoms you’d expect if your life suddenly changed dramatically and you were no longer able to sleep due to a screaming baby. In most cases, women need family support and help, not a diagnosis and pills. But in this country, we label what is a perfectly normal response to a stressful time a mental illness.
PPD affects 10% to 15 % of women during the first year after delivery. See Goodman, J. H., & Santangelo, G. (2011). Group treatment for postpartum depression: a systemic review. Achieve of Women’s Mental Health, 14, 277-293. Prevalence rates for postpartum blues are between 40% and 80% of women who experience childbirth. See Buttner, M., O’Hara, M. W., & Watson, D. (2012). The structure of women’s mood in the early postpartum. Assessment, 19, 247-256.The research is out there in abundance, even if the DSM is not where it should be. Katherine is correct. Further, while you are spot on that more family support is needed, failure to create a diagnosis and respond as best we can in lieu of such support, which too many women lack, is irresponsible and dangerous. Simply declaring it is over diagnosed is akin to the judgmental person who would say a person experiencing major depression just needs to “suck it up.” More compassion and support is what is needed, not downplaying.
Katherine, thank you for mentioning what page from DSM 5 in regards to postpartum.
I am delighted to read an informed person about ppd. I have been pleading with OBYNS and PEDIATRICIANS for 15 years to use the Edinburgh screening test. It must be basic sexism – as a colleague said: If 10-15% of fathers suffered these symptoms, every one of them would be screened Ron Soderquist, Ph.D. Westlake Village,Ca. .
I am replying to Jen: I agree that the DSM-5 and psychiatry in general is calling perfectly normal responses to stressful times “mental illness.” I don’t think that means we don’t offer help, but it shouldn’t be an “mental illness.” It’s very possible that a woman could lose custody of her children over such a diagnosis in certain circumstances. With sexual abuse victims, it had been proposed to describe symptoms as a “paradigm” rather than disorder. In other words, there are all kinds of variating outcomes from this event and “here they are” rather than labeling variations as a “disorder” and thus a “mental illness.” We don’t need to label a broken arm as an illness to recieve treatment. I don’t believe we need to call post partum depression (or a great many other “disorders” listed in the DSM) “mental illness” in order for women to get the help they need.
Just for clarification, the onset of the symptoms must be within 4 weeks, not the diagnosis. In other words, as a licensed therapist, if I see a client who gave birth 6 months ago, when I ask her when her symptoms started,(even one symptom) if she says something like “a few weeks after I gave birth” or “several months ago” that’s enough to qualify for the specifier.
Cheri LCSW, Therapist
Cheri – hi! I have a young mom (19) who just came into my practice. Very smart. She is 10 weeks postpartum with classic MDD symptoms. I think she’s been depressed throughout her pregnancy. Dad is 1st generation and she is 2nd generation Mexican-American. Lots of family pressure to conform to the “good mother” stereotype, which in this case I think she’d actually like to do!!!! But Dad is very judgmental, dismissive of her new challenges and there are language barriers (she doesn’t speak Spanish, his family speaks little English). Hesitant to apply the MDD, and considering an adjustment disorder dx. Any thoughts? Thanks
Sue, LPC, therapist
I am incredibly frustrated!! What the heck???
I am staggered that I cannot be more specific regarding PPD using the DSM-5. It had not occurred to me to look for it until a client with classic symptoms walked into my office. I really dislike being unable to accurately describe what is going on with my clients, since I “have to” diagnose in order to bill….
I don’t think it sounds like the new DSM adequately addresses a diagnosis for postpartum. Most of the women I see in my practice don’t meet criteria for MDD, and are more at an adjustment disorder level, but still have significant struggles with anxiety and depression related to childbirth and related life changes. Further, I see these women presenting usually up to a year postpartum- certainly not only 4 weeks. I hope this diagnosis descriptor limitation doesn’t prevent anyone from seeking treatment or limit MD’s for referring for treatment.
Agree for 20 years have I been using the EPDS screeing tool.
I am relatively new to post partum clients, after leaving for maternity for 2 children and now returning with a new interest in helping women in this time of there lives. Could we possibly better describe some of what is going on as adjustment disorder? Especially using the specifiers (depressed, anxious, mixed, emotions and conduct…etc). would this be a way to bill without “diagnosing” these poor women into a potentially damaging label while being able to capture the cases that are in fact just a response to increase in stress from this life event? Especially because the majority of women I see are NOT 4 weeks out.