I. Case summary The patient, female, 32 years old, was admitted to the hospital on 2009-3-10 with the main reason of “2 weeks after cesarean section, depression, insomnia and few words for 4 days”. The patient was delivered by cesarean section 2 weeks ago due to “36+5 weeks of menopause and low amniotic fluid”, and delivered a live baby girl weighing 2.85 kg with an Apgar score of 10.10. The fetus was healthy and was not breastfed after delivery. She is not interested in anything, not even close to the child, not willing to communicate with her family, not talking much, occasionally she shed tears and is sad, her memory and attention are reduced, with dizziness and tinnitus. Since the onset of the disease, he had poor appetite, insomnia and dreaminess, and normal bowel movements. Past history: past physical health, no history of hypertension, diabetes mellitus, heart disease, etc. Denied history of depression, dysthymia, etc. and family history. Menstrual and marital history: past menstruation was regular, the first menstruation was 14 years old, the cycle was 28 days, and the period was 5 to 7 days. Last menstruation: 2008-6-12. 28 years old, married, 2 pregnancies and 1 delivery. 2009-2-24: Cesarean section for “menopause of 36+5 weeks, low amniotic fluid”, delivered a live baby girl. 2004: abortion. The daughter and her loved one are healthy. Admission physical examination: stable vital signs, clear consciousness, indifferent, no pallor, no abnormal cardiopulmonary auscultation. The abdomen was flat and soft, and a transverse fresh surgical scar was visible at 3 transverse fingers on the pubic bone in the lower abdomen with grade A healing. Gynecological examination: no abnormalities in vulva-vagina, smooth cervix, anterior uterus, uterus descending into the pelvic cavity, about 2+ months gestation size, no pressure pain, no abnormalities palpable in both adnexal areas. Auxiliary examinations: the six female hormone tests were in the normal range, liver and kidney functions, four coagulation tests, nail function, gynecological ultrasound and other tests were all abnormal. Diagnosis and treatment: The patient was diagnosed with puerperal depression. Through psychological counseling, the psychiatrist first communicated with the patient’s family to understand that no major life events had occurred recently and that the family had taken good care of the patient. After communicating with the patient, it was found that the patient was worried about her child getting sick all the time and was anxious about her inability to raise her child, and she even thought of committing suicide. However, he was worried about the survival of the child after the suicide, so he wanted to take the child with him to die. Therefore, the patient forced himself to stay away from the child because he was afraid that he would kill the child by accident if his thoughts were disturbed. After fully understanding the patient’s anxiety and fears, she was given a score of 9 on the Edinburgh Postnatal Depression Scale. Through careful guidance and encouragement, as well as the active cooperation of the family (especially her husband), the patient was given unfailing care and love, and psychotherapy was carried out together, so that the patient felt strongly supported, respected and understood, and her self-confidence was rapidly increased. The patient’s potential motivation is stimulated to strengthen self-control, cope with his own problems, establish good communication skills with others, and instruct the patient to develop good sleep habits. Amitriptyline was administered orally at a starting dose of 50 mg/day. After seven days of medication, the patient felt that the dizziness and tinnitus disappeared, no longer wept secretly, gradually increased his speech, and was willing to take the initiative to communicate with his family and be close to his children. After professional psychological counseling and taking antidepressants for 1 week, the patient gradually improved, her face began to smile, her sleep, memory and attention had gradually returned to normal, and she could handle basic daily life and work. Case analysis Postpartum depression refers to the depressive symptoms of mothers during the puerperium, and is the most common type of puerperal psychiatric syndrome. Most of the symptoms appear within 2 weeks after delivery. The incidence rate is high, 3.5%~33% in foreign countries and 3.8%~16.7% in China. Puerperal depression not only has adverse effects on the mother and seriously endangers her physical and mental health, but also leads to cognitive, emotional, personality and behavioral disorders of the baby and disharmony in family relationships. The main reasons for its occurrence are: ① Psychological factors: this patient is an only child, late in marriage and late in childbirth, and is the jewel of her parents in the boudoir, self-centered in everything and accustomed to the care and support of others. After the birth of her child, her family’s attention was divided, and she did not adapt to the change of role in the short term, resulting in a huge psychological gap. Comparing the vast difference between postpartum and premarital body, overweight, loose abdominal muscles, etc. can cause distress, and invariably increase the mental load. ② Social factors: the biological clock reversal of the premature baby, so that she is exhausted, do not get enough sleep and rest. And the patient’s appetite decreases after delivery, and her family members consider the puerperium and restrict her spicy food, etc. The change in eating habits leads to family tension. ③ Endocrine factors, due to the sharp decline of estrogen and progesterone after delivery, followed by a decrease in the role of catecholamines, leading to corresponding changes in mood and behavior. Lessons learned: Do prenatal health care, strengthen spiritual care for pregnant women, popularize general knowledge about pregnancy and childbirth using various channels such as maternity schools, reduce maternal tension and fear of pregnancy and childbirth, and improve self-care. Promote mutual support among family members, especially the support of spouses, to reduce various stresses of pregnant women; use language skills when medical personnel provide services to avoid negative effects of medical origin, such as: it is not appropriate to arrange normal mothers to live with mothers who give birth to deformed babies, stillbirths or stillbirths; the process of delivery and pain have a greater impact on postpartum depression, and give full care and love to the process of delivery; treat women with high-risk factors (pre-pregnancy Early intervention for those with high-risk factors (abnormal emotion before pregnancy, surgical delivery, difficult delivery, stalled delivery, etc.), and timely psychological counseling and guidance. Expert’s commentary Peripartum depression is an emotional disorder in a special period of a woman’s life, which is a common and serious medical problem, but many cases are under-diagnosed and under-treated. In recent years, scholars at home and abroad have become increasingly concerned about the high prevalence of puerperal depression and the tragic outcomes caused by underdiagnosis and under-treatment. A large prospective Australian cohort study on perinatal mental health collected data on 35,374 women with EPDS prior to delivery from 2002 to 2005 using the Edinburgh Postpartum Depression Scale (EPDS) and the Psychosocial Risk Factor Questionnaire, and found that prior depression and lack of spousal support were major risk factors for women with puerperal depression prior to delivery. The etiology of puerperal depression is complex and includes endocrine, genetic, psychological and social factors. The typical symptoms are: ① Mood changes: depressed mood, frustration, emotional indifference, even anxiety, fear, irritability, aggravated at night; sometimes it is manifested as loneliness, reluctance to meet people or sadness, tears. ② Decreased self-evaluation: self-loathing, self-guilt, hostility to people around, incompatibility with family and husband. ③ Impaired creative thinking and reduced initiative. ④ Lack of confidence in life, feeling that life is meaningless, anorexia, sleep disorders, easy fatigue, decreased sexual desire. In severe cases, there is even despair, suicidal or infanticidal tendencies, and sometimes fall into confusion or lethargy. At present, there are no specific laboratory indicators and unified diagnostic criteria for puerperal depression at home and abroad, and most of them are based on the self-rating scales of various symptoms, and the decision is made by the corresponding scores. At present, the more commonly used criteria are the “Diagnostic criteria for puerperal depression” formulated by the American Psychiatric Association in 1994 in the Diagnostic and Statistical Manual of Mental Disorders. Strengthening mental health care during pregnancy and childbirth and improving social support can help reduce the occurrence of puerperal depression. At present, the treatment of puerperal depression mostly adopts a comprehensive treatment method based on psychotherapy, supplemented by medication when necessary. The types of medication are as follows: 1. tricyclic antidepressants: early first-generation drugs such as promethazine and amitriptyline; second-generation drugs such as maprotiline and ethoxyphenoxymorpholine; the latest third-generation antidepressants are fluphenazine, etc. 2. selective 5-HT reuptake inhibitors: such as fluoxetine, sertraline and paroxetine, etc. If a person suffers from depression during pregnancy or has a history of puerperal depression, it is beneficial to give prophylactic antidepressants immediately after delivery.3. Estrogen therapy: Estrogen has a variety of neuromodulatory functions, including direct intracellular utility and indirect utility on the 5-HT system, and in specific female populations, these utilities may work together to exert antidepressant effects.4. Monoamine oxidase antidepressants: Non-selective and non-reversible. The characteristics of non-selective, non-reversible. Fast onset of action, side effects, generally not as the drug of choice. The puerperal depression is related to endocrine factors, genetic factors, psychological factors and social factors, so we should use medical psychology and sociological knowledge to provide more care and love to mothers during delivery and puerperal period, especially the support of spouses, assess the relevance of suspected patients to these causes, and take timely and targeted preventive measures to prevent the occurrence of puerperal depression.