Page 31 - Layout 1

MEDICAL YEAR
IN REVIEW

Many factors can contribute to the development of postpartum de- pregnant women. With this patient, I was struck by how much resist-
pression, including, but not limited to, biology, stressful life events, ance there was to readily available treatments when she was clearly suf-
prematurity of infants, low income, poor marital relationships and ma- fering. There is significant stigma associated with mental illness, and
ternal abuse. The mother I saw was exposed to several of these factors; patients may forgo treatment to avoid label attachment. Stigma in peri-
elements of this mother’s story are not uncommon in those affected by partum depression patients can be exacerbated by society’s judgment
peripartum depression. For example, domestic violence, before, during of mothers’ care for their children. Finally, I learned that providing psy-
and after pregnancy, is associated with increased odds of peripartum choeducation to patients regarding therapy in addition to medication
depression. Additionally, mothers of preterm infants have an increased management, can help build patient rapport. With this patient, sug-
risk of postpartum depression compared to those of term infants. gesting journaling as a way to process her emotions, in addition to
Women experiencing postpartum depression may normalize their tracking her thoughts and moods, provided comfort as she would be
symptoms. Similarly, this mother normalized her sadness. Although able to document the effect of the medications. I hope to improve my
the circumstances of her life contributed to her depression, she did not ability to assess what stage of change a patient may be at and tailor
realize she was struggling beyond a normal physiologic response. The counseling based on a patient’s concerns. In this encounter, our con-
social worker’s attunement to the patient’s situation and her symptoms, versation may not have fully influenced the patient’s preconceived no-
led to screening and treatment of the depression. Interacting with this tions of mental health care, however, her openness to try different forms
mother served as a reminder of the importance of exploring a patient’s of therapy was enlightening.
concerns beyond their “chief complaint.” I find that I pay closer atten- A multitude of factors can contribute to the development of peripar-
tion when taking the social history to have a well-rounded view of what tum depression. During our pre-clerkship years, most of our curriculum
the patient is experiencing. focused on pathophysiology and treatments of conditions. However, a
couple of interactions with patients affected by peripartum depression
Emily: have already illustrated that the psychosocial aspects of our patients’ lives
“While at the prenatal clinic, I met a pregnant woman with gestational significantly impact their medical care. These experiences taught us to
diabetes who had been started on insulin and was asked to keep a blood consider the biological, psychological, and social components of a pa-
glucose log at her last visit. Her log had many entries missing, but meas- tient, to screen for peripartum depression, regardless of whether we are
urements recorded were in the 200s, well above what would be healthy in OBGYN, pediatrics, family medicine, psychiatry or other areas of
for her and her growing baby. As the resident explored the lack of consis- medicine. Undoubtedly, these components will help us identify other ill-
tency with checking her blood sugars, she described difficulty getting out nesses too. Thus, as we continue to grow our clinical skills, we hope to
of bed and making meals, feeling guilty that she wasn’t taking care of her- shape our ability to care for individuals, not just their conditions.
self and difficulty focusing on household chores. We discussed the diagnosis
of peripartum depression, how common the diagnosis was, and how ben- References:
eficial treatment could be. In response, our patient burst into tears. Once American Psychiatric Association. (2013). Diagnostic and statistical
she composed herself she questioned: “How does this medication work? manual of mental disorders (5th ed.). https://doi.org/10.1176/
How long would I need to take this for? After my pregnancy, too? How appi.books.9780890425596
would I know if it worked?” After a lengthy discussion, she verbally agreed Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S.,
to try the medication we recommended, but her body language remained Gartlehner, G., & Swinson, T. (2005). Perinatal depression: A system-
guarded. When I returned to the room, I asked if she wanted to talk more atic review of prevalence and incidence. Obstetrics and Gynecology,
about our recommendations from today’s visit. In the end, discussing her 106(5 Pt 1), 1071–1083. https://doi.org/10.1097/01.AOG.00001
fears about whether psychiatric medication would change her personality 83597.31630.db
was what seemed to put her most at ease. We also explored adjunctive ther- Dinwiddie, K. J., Schillerstrom, T. L., & Schillerstrom, J. E. (2018).
apies, such as journaling and mindfulness, while she waited for available Postpartum depression in adolescent mothers. Journal of Psychoso-
psychotherapy services.” matic Obstetrics and Gynecology, 39(3), 168–175.
Significant barriers illustrated in this encounter included uncer- https://doi.org/10.1080/0167482X.2017.1334051
tainty regarding psychotropic medication safety and efficacy, in addi- Moses-Kolko, E. L., & Roth, E. K. (2004). Antepartum and post-
tion to stigma about psychotropic medications. Counseling this partum depression: Healthy mom, healthy baby. Journal of the Amer-
mother taught me to understand medication safety and side effect pro- ican Medical Women’s Association (1972), 59(3), 181-191.
files from the perspective of a patient, especially when working with Koire, A., Nong, Y. H., Cain, C. M., Greeley, C. S., Puryear, L. J., &
continued on page 32
Visit us at www.bcms.org 31