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Referral and warning signs
When to refer
Refer to Mental Health Specialist/Hospital for: Severe depression, Suicidal/homicidal ideation (URGENT), Psychotic symptoms, Non-response, Complex Rx needed.
Red flags
- Thoughts of harming self or baby
- Psychotic symptoms
- Severe functional impairment
- Rapidly worsening symptoms
- Refusal of food/fluids
Signs and symptoms
- Persistent low mood, sadness, tearfulness (>2 weeks).
- Loss of interest/pleasure (anhedonia).
- Fatigue, low energy.
- Sleep disturbances.
- Appetite changes.
- Feelings of guilt, worthlessness, inadequacy.
- Difficulty concentrating.
- Anxiety, irritability.
- Negative feelings towards baby / excessive anxiety.
- Thoughts of death/suicide or harming baby (less common, severe).
Risk factors
- Previous depression/anxiety.
- Previous PND.
- Stressful life events.
- Lack of social support.
- Difficult childbirth.
- Unplanned pregnancy.
- Infant health problems.
- History of abuse.
- Young age.
- Socioeconomic disadvantage.
Diagnosis
Clinical assessment
Screening questions during PNC visits. Clinical interview assessing depressive symptoms (duration >2wks, severity, impairment). Differentiate from 'Baby Blues' (milder, transient <2wks).
Investigations
- Exclude organic causes (Anaemia, Thyroid dysfunction - TSH).
Diagnostic criteria
Meet criteria for Major Depressive Episode with postpartum onset.
Management
Non-pharmacological management
- Watchful Waiting (Mild/Baby Blues): Support, reassurance, education, review.
- Psychosocial Support: Active listening, encourage practical help, peer support, self-care.
- Psychological Therapies (Mild-Moderate): Structured counseling (problem-solving, IPT, CBT) - requires trained providers.
Pharmacological treatment
- Antidepressants (Moderate-Severe or unresponsive Mild): SSRIs first-line (Fluoxetine 20mg OD, Sertraline 50mg OD - preferred if breastfeeding). Start low, titrate. Continue 6-9m post-recovery. TCAs alternative.
- Severe PND/Psychosis: Requires specialist Rx (antipsychotics, mood stabilizers, inpatient).
Monitoring
Regular follow-up (symptoms, adherence, side effects, function, bonding, safety).
Complications
- Impaired mother-infant bonding.
- Negative impact on infant development.
- Relationship problems.
- Chronic depression.
- Suicide (rare).
- Infanticide (very rare).
Prevention
- Identify women at risk antenatally.
- Provide social support.
- Early detection/intervention.
- Psychoeducation.
Patient education
- Explain PND as treatable illness.
- Differentiate from baby blues.
- Treatment options.
- Importance of self-care/accepting help.
- Medication info (incl breastfeeding safety).
- Recovery takes time.
- Support resources.
Uganda-specific notes
Often under-recognized/treated. Integrate screening into PNC. Focus on psychosocial support/community links. Fluoxetine common SSRI.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.6.2
- Uganda Clinical Guidelines (UCG) 2023
Chapter 9 (Mental Health)