Postpartum Support International and the DSM 5
An excerpt from the full article, “Postpartum Depression and Perinatal Mood Disorders in the DSM”” (PDF)
In October 2010, at the biennial meeting of the Marcé Society and PSI annual conference held in Pittsburgh, we heard a panel presentation on the DSM-5 revisions in which it was revealed that the postpartum onset specifier would not be extended, and that the committee did not find persuasive evidence to indicate that postpartum depression is distinct from other existing depressive disorders.
There was a palpable reaction in the audience and during the opportunity for Q&A, lines quickly developed behind the microphones. PSI members bravely walked to the microphone and in front of a large audience of perinatal researchers, professionals, and PSI members, made the concise argument that the conclusions of the workgroup seemed a disservice to many women. In particular, many PSI members have commented on the contributions of Katherine Stone from Postpartum Progress and Adrienne Griffen from Postpartum Support Virginia. Additionally, a PSI professional member posed an incisive question, asking whether the methods of data analysis, interpretation, and conclusion were consistently applied across all of the workgroups of the DSM-5 revisions, and asserted that systemic consistency would give the greatest credibility to the whole project.
During the process of public input and testimony for DSM5 revisions during 2012, PSI was invited to the American Psychiatric Association briefing meeting held in May. PSI Representative Lorraine Caputo, LCSW, attended the meeting, and we further followed up with letters to the review committee.
In our input to the committee we wrote:
We continue to support the recommended addition of a specifier, as it is stated on the DSM 5 website, “With Postpartum Onset,” that can be applied to a current or most recent Major Depressive Episode, Manic, or Mixed Features in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder, or to Brief Psychotic Disorder, and that the onset of the episode be extended to within 6 months postpartum.
We would also recommend, very highly, the addition of the 6 month onset specifier to the Mixed Depression and Anxiety Disorder andObsessive Compulsive Disorder as well, for the following reasons: In general many postpartum women present with a mixed depression and anxiety picture so the Mixed Depression and Anxiety Disorder seems to be a recognizable diagnosis for primary care doctors and obstetricians who will see many of these women in their practices. In addition, it is important for doctors and other mental health professionals to be trained to diagnose postpartum depression, anxiety, OCD and psychosis to insure the proper treatment and education of their patients and their families. Many families do not understand the nuances of these conditions in the Perinatal time period and depend on solid information and diagnosis to help them know how to support their loved ones. In addition, many women who develop OCD in the postpartum period often have intrusive thoughts about hurting themselves and/or their infants. General practitioners and obstetricians will utilize the DSM 5 to help them recognize this OCD in the context of postpartum depression and anxiety.
As you know Postpartum Support International is a worldwide organization made up of over 600 professional and non-professional members, both individual and institutional. Our membership vocalized their concerns about the DSM 5 and the importance of recognizing the 6 month onset of this condition in affective disorders at the International Marce/PSI conference in Pittsburgh. We are grateful that our voices were heard in this matter. We hope you will consider our additional recommendations in this letter.
DSM-5 and Depression in Postpartum Period
When the new DSM-5 was published, there was a notable revision to the Diagnosis of Major Depressive Disorder, which was the removal of the bereavement exclusion. In prior DSM classifications, individuals with significant depressive symptoms that occurred within two months of the loss of a loved one were excluded. DSM-5 recognizes that while symptoms are understandable, the clinician should carefully consider the possibility of a Major Depressive Disorder in addition to normal sadness resulting from loss.
What about the postpartum onset specifier? In DSM-5 the diagnosis of depression during the postpartum period still utilizes the onset specifier format. However the specifier has changed it is now titled “with peripartum onset” which is defined as the most recent episode occurring during pregnancy as well as in the four weeks following delivery. This official recognition of depression during pregnancy represents a significant step forward! It is however disappointing that the period following delivery was not extended to recognize that real suffering often occurs during the first year, as PSI and others had lobbied.
What happened? As noted by O’Hara and McCabe in a recent review of the status of postpartum depression , the DSM-5 mood disorders workgroup did consider extending the four week specifier from 4 weeks to 6 months. In this review they also aptly note that, indeed in clinical practice and research, regardless of the DSM criteria, women with a depressive disorder onset within 12 months of birth are often classified as having “Major Depressive Disorder, with postpartum onset.” Yet, the workgroup decided that ultimately the available epidemiological evidence to support such an extension was not yet compelling.
Toward the Future
We are encouraged that the DSM now includes depression during pregnancy, which represents a significant revision and a step forward, especially considering the recognition of depression in postpartum women is relatively recent. It is also significant that it acknowledges the co-existing symptoms of anxiety and panic. “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.” However, in contrast, there is considerable disappointment that the time frame for postpartum depression was not extended. It is obvious that we need more published research on the time frame of symptom onset during the year after childbirth. We hope that a future revision will include the later onset of symptoms as well as the peripartum onset specifier for anxiety disorders, obsessive disorders, and hypomania, which will provide crucial diagnostic and treatment guidance.
It is important to clarify that although that the DSM has been casually referred to as “the bible” of diagnosis and assessment, PSI and other allied organizations are full of trained perinatal mental health professionals, supporters, and survivors who do understand the elements for which we advocated through the DSM revision: the broader time of onset, the importance of diagnostic and statistical criteria through specifiers for anxiety, mixed anxiety/depressive disorder, obsessive disorder, hypomania, and traumatic stress disorders.
As an organization, PSI will continue to advocate for more research to clarify the range of onset and recovery, and to bring that research to light in any further DSM revisions. However, the wait for those changes does not stop any of us from acting on our more direct and immediate goals: to continue to increase public and provider awareness with reliable information and access to support, expressing the real experiences of pregnant and postpartum mothers and fathers and increasing the numbers of trained providers to offer reliable, compassionate, and informed care and treatment.