Depression OSCE - Postnatal Depression

Case Overview

• Age/Sex: 32/F
• Occupation: Primary school teacher (on maternity leave)
• Setting: GP appointment — 3 months postpartum
• Chief complaint: "I'm feeling low and tired"

Patient Script

Who I Am

I'm 32 years old, a primary school teacher, and I'm three months after having my first baby.

What Brings Me In

I've been feeling low, exhausted and not like myself for a few months and I thought I should get it checked.

My Story

I had a straightforward delivery three months ago and my baby is healthy. About 6 weeks after the birth I started to notice I'm feeling down most days, crying easily, and I just don't enjoy things I used to. At first I thought it was just the lack of sleep from the baby, but it's been getting worse over the last two months. I can manage the baby’s basic needs but I find it hard to get out of bed, I have no energy, and I don't feel like doing things I used to like, like reading or meeting friends. I'm worried I'm a bad mum because I don't feel bonded with her the way I expected. I sometimes have short, embarrassing thoughts like "what if I dropped her" — I would never act on them, but they upset me and make me feel guilty. I tried to push through but my partner says he's worried about me. I started the combined oral contraceptive about a month ago because we wanted contraception — maybe that's affecting my mood? I was also told in pregnancy that my iron was a bit low and I took iron tablets for a few weeks.

My Medical Background

• Past medical history: gestational diabetes controlled with diet (resolved postpartum)
• Medications: ferrous sulfate intermittently after delivery; started combined oral contraceptive 4 weeks ago
• Allergies: none
• Social: lives with partner (works full-time), partner is supportive; on maternity leave; no children previously
• Substance use: drinks an occasional glass of wine at weekends (1–2 units); never smoked
• Family history: mother had "a bad patch" after her baby but wasn't treated formally

What I Think & Worry About

• I think I might just be exhausted from the baby and not getting sleep.
• I'm worried I'm a bad mother and that I'll never feel like myself again.
• I want to know if this is normal and what will help — I don't want to be on medication if I don’t need it.

If You Ask Me About Other Symptoms...

• Sleep: "I wake a few times to feed the baby; when she sleeps I can’t get to sleep easily — I lie awake worrying."
• Appetite/weight: "My appetite's a bit less but I haven't lost much weight; I snack on biscuits when I feel low."
• Energy/concentration: "Very low energy; I can't concentrate on reading or planning things for work."
• Anxiety/panic: "I do worry a lot, especially about whether I'm doing things right; no sudden panic attacks."
• Suicidal thoughts/infant harm: "I have had fleeting awful thoughts about dropping her — I would never do that. I haven't made any plans and I don't want to hurt myself."
• Physical symptoms: "Sometimes I feel palpitations — probably after too much coffee."
• Breastfeeding: "I'm breastfeeding mostly, a few formula feeds now and then."
• Recent life events: "Partner returned to work last week so I'm alone more in the day; my sister had a baby 2 years ago and she seemed fine which makes me feel worse."

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Clinical Summary

Examination

• Appearance: appropriate dress, tearful during history, poor eye contact at times
• Vitals: BP 118/76 mmHg, HR 78 bpm, Temp 36.7°C
• BMI: 24 kg/m2
• Cardiovascular/respiratory/abdominal: unremarkable on brief exam
• Mental state: depressed affect, slowed speech, reduced interest in conversation, coherent thought form, denies current suicidal intent or plans, acknowledges occasional intrusive distressing thoughts, insight present

Investigations

• Full blood count: Hb 11.4 g/dL (mild anaemia) (may contribute to tiredness)
• Ferritin: 18 µg/L (low) (consistent with iron deficiency)
• Thyroid function (TSH): 1.8 mIU/L (normal) (makes hypothyroidism unlikely)
• Urine pregnancy test: negative (not pregnant)
• Edinburgh Postnatal Depression Scale (EPDS): 17/30 (score ≥13 suggests probable postnatal depression)

Diagnosis

• Primary diagnosis: Postnatal (postpartum) depression

  • Evidence: onset within postpartum period (symptoms began ~6 weeks postpartum), persistent low mood, anhedonia, fatigue, impaired concentration, guilt/poor bonding, EPDS 17, significant functional impact

• Differential diagnoses:

  • Postnatal "blues": timing less likely — blues peak in first 2 weeks and resolve by 2 weeks postpartum; this patient's symptoms are persistent and worsening over months
  • Adjustment disorder with depressed mood: possible if stressors predominate, but symptom severity and functional impairment favour depressive disorder
  • Hypothyroidism: TSH normal — unlikely
  • Iron deficiency anaemia: low ferritin and mild anemia may contribute to fatigue but does not explain mood change alone
  • Sleep deprivation: contributes to symptoms but does not fully account for pervasive low mood and anhedonia

Management

• Immediate safety assessment and documentation: patient denies active suicidal ideation or plan; fleeting intrusive thoughts about infant without intent — arrange close follow-up and provide crisis contact details; involve partner with consent
• Address reversible contributors: start oral iron therapy and advise dietary measures for iron deficiency
• Offer perinatal mental health referral/psychological therapies: provide prompt referral for cognitive behavioural therapy (or interpersonal therapy) tailored to postpartum women
• Discuss pharmacotherapy: discuss benefits and risks of SSRIs (sertraline preferred in breastfeeding) if symptoms do not improve or are moderate/severe; involve patient in shared decision-making
• Practical support: advise on sleep hygiene, partner support, community resources (postnatal support groups, health visitor), consider adjusting feeding plan if necessary for medication decisions
• Follow-up: arrange review in 1–2 weeks (earlier if deterioration) and ensure safety plan and emergency contacts are given

Key Learning Points

• Postnatal depression typically presents within the first few months after delivery with persistent low mood, anhedonia, guilt, impaired bonding and functional impairment — distinguish from transient "baby blues" by duration and severity.
• Use screening tools (EPDS) and assess safety explicitly (suicidal ideation and intrusive thoughts about the infant); manage risk urgently if present.
• Management involves a combined approach: psychosocial support and therapy first-line for mild–moderate cases, with SSRIs (e.g., sertraline) considered if indicated; also treat contributing medical issues (e.g., iron deficiency) and coordinate perinatal mental health services.