Should postpartum mood disorders be given a more prominent or distinct place in the DSM‐IV?

Abstract

In this review we consider the literature on postpartzcm psychosesas wellas on nonpsychotic postpartum depression with a goal of determining how such disorders shouId be categorized in DSM-N. We concIude that the majority of postparrum psychoses are affective in nature and that, despite the observation of '%onjhon" in many such presentations, the symptom picture is not suflciently unique to wart-ant a separate diagnostic category. We could $nd no evidence of unique presentation of non-psychotic postpartum depression. Nonetheless, because of the unique complications associated with postpartzcm disorders (e.g., disruption of the mother-infant bond, infanticide), we recommend that postpamm presentations be given a more prominent place in the text of DSM-IV and that a course spea@r, "post pa. Eum onset," be applied to major depressive or manic/hypmnis epicodes in Bipolar I, Bipolar 11, or Major Depressive Disorder, or to Acute Psychotic Disorder when appropriate . Depression 1:59-70 (1993). 0 1993 WiIeyLks, Inc.

Diagnosis and treatment of depression in primary medical care practice: The application of research findings to clinical practice

“…Premenstrual dysphoric disorder is characterized by multiple symptoms during the luteal phase of the menstrual cycle (e.g., depressed mood, anxiety, affective lability) which markedly interfere with social or occupational functioning. Fifty to eighty percent of women experience mild postpartum disphoria, or the "baby blues," which typically occurs 3-7 days after delivery and lasts from 1-14 days; 10%-15% of women experience the more severe postpartum depression (Purdy & Frank, 1993). Menopausal symptoms parallel those of depression and include sleep disturbance, fatigue, irritability, and other mood changes.…”

A Tricky Object to Classify: Evidence, Postpartum Depression and the DSM‐IV

“…Despite James Hamilton's efforts to argue that there was enough evidence to include PPD as distinct a disorder, the MDC members excluded PPD as a separate diagnostic category based on Purdy's and Frank's (1993) literature review. The definitions of evidence employed in their review, which were significantly influenced by the neo-Kraepelinian revolution in psychiatry, deemed the clinically based data provided by Hamilton as almost entirely irrelevant.…”

“…Documents included published research literature that was relied on by the members of the MDC to inform their decisions about PPD, meeting agendas and minutes, formal and informal internal correspondence between individuals working on the MDC and other DSM‐IV work groups, letters to and from individuals that were not directly involved in the DSM‐IV revision process (i.e., professionals and the public), drafts of DSM‐IV text, comments by reviewers of these drafts, and subsequent revised drafts of DSM‐IV text. In terms of the analysis presented in this paper, key archival documents included: (1) the PPD evidence‐based literature review by Daniel Purdy and Ellen Frank () which was included in the APA's Sourcebook Reviews , a series that was formally published by the association but was not widely circulated beyond the members of the APA (although is now easier to obtain in the age of electronic databases), and (2) letters from Dr. James Hamilton to the DSM‐IV Task Force and the MDC. The argument presented in this paper also relies on published psychiatric research literature as primary source material because definitions of evidence were often established by referencing these scholarly works.…”

“…In addition to relying on Robins’ and Guze's work to provide direction regarding the use of research‐based evidence over evidence produced in a clinical setting, Purdy and Frank () also established their own inclusion and exclusion criteria that dictated what research literature would be included in the evidence‐based review:

Sources were limited to English language publications and translated articles or abstracts… only articles that included diagnoses made according to a standardized set of criteria (e.g., Research Diagnostic Criteria, DSM , International Classification of Diseases), as opposed to using a single rating scale, were included, unless the paper provided important information (e.g., sleep or neuroendocrine data) not available in better characterized samples or was written before the era of specified criteria sets . Those articles describing admissions to psychiatric hospitals (or referral to psychiatric outpatient care in the British system) within 4 weeks parturition were also included, on the assumption that hospitalization was an indicator of sufficient severity of illness to warrant inclusion…Studies were included only if the sample size approximated a minimum of 50 subjects, unless the study provided specific information that was directly relevant to Robins and Guze validators and was considered to be of particularly high quality (Purdy & Frank, , p. 263; emphasis added).

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“…In addition to relying on Robins' and Guze's work to provide direction regarding the use of research-based evidence over evidence produced in a clinical setting, Purdy and Frank (1993) also established their own inclusion and exclusion criteria that dictated what research literature would be included in the evidence-based review:…”