Overview of Postpartum Depression

Postpartum depression (PPD) is a subset of perinatal depression that occurs to mothers after childbirth, and it also has negative effects on the baby. Health-care professionals who identify PPD and coordinate access to treatment are providing a protective factor for children and promoting their healthy social-emotional development, according to a policy statement from the American Academy of Pediatrics (AAP, 2019).

Screening for postpartum depression is a Medicaid benefit and can be performed during any Texas Health Steps preventive medical checkup or follow-up visit up to the infant’s first birthday. Texas Health Steps providers can receive separate reimbursement for conducting maternal postpartum depression screening as outlined in this course.

“PPD meets the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5] as a major depressive disorder. Anxiety is a common component of PPD” (Ibid.). Postpartum depression is a spectrum of psychological conditions, encompassing the milder symptoms of postpartum blues to the severe symptoms of postpartum psychosis.

Postpartum Blues

As many as 80 percent of mothers have temporary mild postpartum emotional symptoms, often termed “baby blues.” Postpartum blues usually begin in the first few days after childbirth and may be present for just a few hours or for one to two weeks. Symptoms, which do not impair function, include crying, depressed mood, irritability, anxiety and confusion (Ibid.). Postpartum blues generally do not require medical treatment, but mothers can benefit from reassurance and referral to education and support resources.

Postpartum Psychosis

Only 1 to 2 people per 1,000 experience postpartum psychosis, with symptoms that may include delusions, hallucinations, mood shifts, paranoia and thoughts of homicide or suicide. Immediate medical intervention is required.

Postpartum depression, the most common form of postpartum mood disturbance, affects a mother’s ability to care for herself and her infant, and adversely affects the critical early period of infant brain development (Ibid.). The AAP policy statement specifies that PPD can lead to:

• Discontinuation of breastfeeding
• Family dysfunction
• Inappropriate medical treatment of the infant
• Increased costs of medical care
• Increased risk of abuse and neglect

The AAP policy statement describes postpartum depression as one of the “most common adverse childhood experiences that are associated with the costliest adverse adult health outcomes.”

“An infant in the environment of significant maternal depression is at risk for toxic stress and its consequences. Toxic stress is an unhealthy prolonged activation of the stress response unbuffered by a caregiver” (Ibid.). The child’s physiologic response to stress affects social-emotional development, placing the child “at risk for impaired social interaction and delays in language, cognitive, and social-emotional development” (Ibid.).

Symptoms of Postpartum Depression

The DSM-5 identifies nine symptoms of major depressive disorder. A diagnosis of PPD requires that at least five of the nine diagnostic criteria be present for two weeks or longer and that symptom 1 or symptom 2 must be present. In addition, symptoms other than symptom 9 must be present and prominent on most days.

Risk Factors for PPD

The greatest risk factor for PPD is a personal history of depression. A history of anxiety or mood symptoms during pregnancy also increases risk. Other risk factors include:

• Caring for an infant with medical issues or a difficult temperament
• Hormonal changes following pregnancy
• Isolation and lack of social support
• Personal or family history of mental illness
• Stressful life situations

Postpartum depression can also occur in the absence of any known risk factors and can have serious consequences for maternal and infant health. Women are more likely to take their babies for regular checkups than to seek care for themselves. Therefore, screening for PPD during an infant’s preventive medical checkup or follow-up visit is one important way Texas Health Steps providers support good health for young Texans and their families.

Stigma and PPD

Depression is still stigmatized in some cultures and communities. A mother may not disclose feelings of sadness for fear of being judged. New parents may not trust psychotherapy or mental health medications. A health-care provider’s thoughtful words and open-ended questions may help with the conversation about the effects of depression on both mother and child. The AAP (2022) recommends that health-care providers begin with questions such as the following:

• “Do you get personal time since you’ve had your baby? Who is helping you with that?”

• “Having a new infant is so hard—full of joys but also a lot of new adjustments. How are you holding up?”

• “When we miss sleep, like with a new infant, we get more moody or worried. How is your sleep? Are you feeling more moody or worried?”

• “It’s common to have lots of emotions with a new baby. Have you been feeling down?”

Texas Medicaid Promotes PPD Screening at the Postpartum Checkup

Postpartum depression screening should be conducted at a woman’s postpartum checkup. Medicaid does not provide separate reimbursement for PPD screening at the postpartum visit but encourages health-care providers to follow best practices and recommendations in screening women who:

• Received prenatal care through Medicaid for Pregnant Women. Women can receive postpartum care up to 60 days after the birth of the baby.

• Remain eligible for Medicaid more than 60 days after giving birth.

• Received prenatal care through the Children’s Health Insurance Program (CHIP)–Perinatal CHIP-P covers up to two postpartum visits, even when coverage otherwise ends at birth.

• Meet eligibility requirements to receive services through the Healthy Texas Women. Most women are automatically enrolled in Healthy Texas Women when their Medicaid for Pregnant Women coverage period ends.