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Depression, Postpartum
Kathryn Myer, MD
Nancy Byatt, DO, MBA, FAPM
image BASICS
DESCRIPTION
  • Major depressive disorder (MDD) that recurs or has its onset in the postpartum period
  • May also occur in mothers adopting a baby or in fathers
  • Postpartum depression (PPD) is similar to nonpregnancy depression (sleep disorders, anhedonia, psychomotor changes, etc.); it most often has its onset within the first 12 weeks postpartum yet can occur within 1 year after delivery.
  • Different than postpartum “blues” (sadness and emotional lability), which is experienced by 30-70% of women and has an onset and resolution within first 10 days postpartum.
EPIDEMIOLOGY
Incidence
14.5% of women have a new episode of major or minor depression during postpartum period (1).
Prevalence
  • More than 50% of women with postpartum depression enter pregnancy depressed or have an onset during pregnancy (2).
  • As many as 19.2% women suffer from depression within 3 months in the postpartum period (3).
ETIOLOGY AND PATHOPHYSIOLOGY
  • May be related to sensitivity in hormonal fluctuations, including estrogen; progesterone; and other gonadal hormones as well as neuroactive steroids; cytokines; hypothalamic-pituitary-adrenal (HPA) axis hormones; altered fatty acid, oxytocin, and arginine vasopressin levels; and genetic and epigenetic factors
  • Multifactorial including biologic-genetic predisposition in terms of neurobiologic deficit, destabilizing effects of hormone withdrawal at birth, inflammation, and psychosocial stressors
RISK FACTORS
  • Previous episodes of PPD
  • History of MDD
  • MDD during pregnancy
  • Anxiety during pregnancy
  • History of premenstrual dysphoria
  • Family history of depression
  • Unwanted pregnancy
  • Socioeconomic stress
  • Low self-esteem
  • Young maternal age
  • Alcohol abuse
  • Marital conflict
  • Multiple births
  • African Americans and Hispanics may have higher rates of PPD.
  • Preterm and low birth weight baby
  • Postpartum pain, sleep disturbance, and fatigue
  • Recent immigrant status
  • Increased stressful life events
  • History of childhood sexual abuse
  • Decision to decrease antidepressants during pregnancy
  • Intimate partner violence (4)
GENERAL PREVENTION
  • Universal screening during pregnancy to allow for detection and treatment
  • Screen using Edinburgh Postnatal Depression Scale during pregnancy and the postpartum year: http://www.testandcalc.com/etc/tests/edin.asp
  • Postnatal visits, psychotherapy, and/or psychoeducation for high-risk women
  • For women with depression during pregnancy, psychotherapy or treatment with antidepressants during pregnancy may prevent PPD.
  • Depression care manager who provides education, routine telephone contact, and follow-up to engage women in treatment
COMMONLY ASSOCIATED CONDITIONS
  • Bipolar mood disorder
  • Depressive disorder not otherwise specified
  • Dysthymic disorder
  • Cyclothymic disorder
  • MDD
image DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
  • Baby blues: not a psychiatric disorder; mood lability resolves within days
  • Postpartum psychosis: a psychiatric emergency
  • Postpartum anxiety/panic disorder
  • Postpartum obsessive-compulsive disorder
  • Hypothyroidism
  • Postpartum thyroiditis: can occur in up to 5.7% of patients in the United States and can present as depression (5)
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
Thyroid-stimulating hormone (TSH), B12, folate and Vitamin D
Diagnostic Procedures/Other
  • Edinburgh Postnatal Depression Scale is a validated screening tool.
  • The Patient Health Questionnare-9 (PHQ-9) is a validated commonly used screening tool.
  • Edinburgh Postnatal Depression Scale (Partner Version): to be completed by mother's partner to obtain his or her view of mother's depression
image TREATMENT
GENERAL MEASURES
  • Outpatient individual psychotherapy in combination with pharmacotherapy
  • Interpersonal psychotherapy and cognitive behavioral therapy
  • Strongly consider pharmacotherapy when symptoms are moderate or severe.
  • Assess suicidal ideation.
  • Assess homicidal ideation and thoughts of harming the baby.
  • Thoughts of harming the baby require immediate hospitalization.
  • Visiting nurse services can provide direct observations of the mother regarding safety concerns and mother-child bonding.
MEDICATION
First Line
  • For nonbreastfeeding women, selection of antidepressants is similar to nonpostpartum patients.
  • Selective serotonin reuptake inhibitors (SSRIs) are generally effective and safe:
    • Fluoxetine (Prozac): 20 to 80 mg/day PO (most activating of all SSRIs)
    • Sertraline (Zoloft): 50 to 200 mg/day PO (mildly sedating)
    • Paroxetine (Paxil): 20 to 60 mg/day PO (sedating)
    • Citalopram (Celexa): 20 to 40 mg/day PO (FDA recommendation)
    • Escitalopram (Lexapro): 10 to 20 mg/day PO
  • Tricyclic antidepressants (TCAs) are effective and less expensive yet also are lethal in overdose and have unfavorable side effects:
    • Avoid TCAs in mothers with a history of suicidal ideation.
  • Bupropion (Wellbutrin): 150 to 450 mg/day PO in patients with depression plus psychomotor retardation and hypersomnia and with weight gain. Bupropion is less likely to cause weight gain or sexual dysfunction and is highly activating.
  • Mirtazapine (Remeron): 15 to 45 mg/day PO at bedtime; may assist with sleep restoration and weight gain; no sexual dysfunction
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
    • Venlafaxine (Effexor XR): a dual-action antidepressant that blocks the reuptake of serotonin in doses of up to 150 mg/day and then blocks the reuptake of norepinephrine in doses of 150 to 450 mg/day PO
    • Duloxetine (Cymbalta): more balanced serotonin/norepinephrine reuptake throughout dosing; 40 to 60 mg/day PO (doses >60 mg have not been demonstrated to be more effective)
    • Desvenlafaxine (Pristiq): 50 mg/day PO
  • Bipolar disorder requires treatment with mood stabilizer.
  • Among breastfeeding mothers
    • Breastfeeding should generally not preclude treatment with antidepressants.
    • SSRIs and some other antidepressants are considered a reasonable option during breastfeeding.
    • All antidepressants are excreted in breast milk but are generally compatible with lactation.
    • Paroxetine and sertraline have lower translactal passage.
    • SSRIs and nortriptyline have a better safety profile.
    • Translactal passage is greater with fluoxetine and citalopram (4)[B].
    • Start with low doses and increase slowly. Monitor infant for adverse side effects.
    • Continuing an efficacious medication is preferred over switching antidepressants to avoid exposing the mother and infant to the risks of untreated PPD (4)[B].
    • P.277

    • Breastfeeding women need additional education and support regarding the risks and benefits of use of antidepressants during breastfeeding.
    • Consider negative effects of untreated PPD on infant and child development.
    • Discussions of the treatment options with the patient and her partner when possible. Take into account the patient's personal psychiatric history and previous response to treatment, the risks of no treatment or undertreatment, available data about the safety of medications during breastfeeding, and her individual expectations and treatment preferences (6)[B].
    • For further information: http://toxnet.nlm.nih.gov/
Second Line
Consider switching to a different antidepressant or augmentation if patient has a lack of response. Electroconvulsive therapy (ECT) is an option for depressed postpartum women who do not respond to antidepressant medications, have severe or psychotic symptoms, cannot tolerate antidepressant medications, are actively engaged in suicidal self-destructive behaviors, or have a previous history of response to ECT (7)[B].
ISSUES FOR REFERRAL
  • Obtain psychiatric consultation for patients with psychotic symptoms.
  • Strongly consider immediate hospitalization if delusions or hallucinations are present.
  • Hospitalization is indicated if mother's ability to care for self and/or infant is significantly compromised.
ADDITIONAL THERAPIES
  • Psychoeducation, including providing reading material for the patient and family
  • Psychotherapy: Interpersonal psychotherapy, cognitive behavioral therapy, and psychodynamic psychotherapy have shown to be effective (5)[B].
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Breastfeeding has been associated with reduced stress and improved maternal mood.
  • Infant massage, infant sleep intervention, exercise, and bright light therapy may be beneficial (7)[B].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Presence of suicidal or homicidal ideation and/or psychotic symptoms and/or thoughts of harming baby and/or inability to care for self or infant, severe weight loss
Discharge Criteria
  • Absence of suicidal or homicidal ideation and/or psychotic symptoms and/or thoughts of harming the baby
  • Mother must be able to care for self and infant.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Collaborative care approach, including primary care visits and case manager follow-ups
  • Consultation with the infant's doctor, particularly if the mother is breastfeeding while taking psychotropic medications
DIET
  • Good nutrition and hydration, especially when breastfeeding
  • Mixed evidence to support the addition of multivitamin with minerals and omega-3 fatty acids
PATIENT EDUCATION
  • This Isn't What I Expected: Overcoming Postpartum Depression, by Karen R. Kleinman and Valerie Davis Raskin
  • Down Came the Rain: My Journey Through Postpartum Depression, by Brooke Shields, 2005
  • Behind the Smile: My Journey Out of Postpartum Depression, by Marie Osmond, Marcia Wilkie, and Judith Moore, 2001
  • Web resources
    • Postpartum Support International: http://www.postpartum.net/
    • La Leche League: http://www.llli.org/
    • http://toxnet.nlm.nih.gov/
    • http://www.mededppd.org/
    • http://www.womensmentalhealth.org/
    • http://www.motherrisk.org/
    • http://www.step-ppd.com/
PROGNOSIS
  • Treatment of maternal depression to remission has been shown to have a positive impact on children's mental health.
  • Some patients, particularly those with undertreated or undiagnosed depression, may develop chronic depression requiring long-term treatment.
  • Untreated maternal depression is linked to impaired mother-infant bonding and cognitive and language development delay in infants and children (8).
  • Postpartum psychosis is associated with tragic outcomes such as maternal suicide and infanticide.
REFERENCES
1. Stuart-Parrigon K, Stuart S. Perinatal depression: an update and overview. Curr Psychiatry Rep. 2014;16(9):468.
2. Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490-498.
3. Bobo WV, Yawn PB. Concise review for physicians and other clinicians: postpartum depression. Mayo Clin Proc. 2014;89(6):835-844.
4. Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1): 1071-1083.
5. Cerulli C, Talbot NL, Tang W, et al. Co-occurring intimate partner violence and mental health diagnoses in perinatal women. J Womens Health (Larchmt). 2011;20(12):1797-1803.
6. Nicholson WK, Robinson KA, Smallridge RC, et al. Prevalence of postpartum thyroid dysfunction: a quantitative review. Thyroid. 2006;16(6):573-582.
7. Pearlstein T, Howard M, Salisbury A, et al. Postpartum depression. Am J Obstet Gynecol. 2009;200(4):357-364.
8. Fitelson E, Kim S, Baker AS, et al. Treatment of postpartum depression: clinical, psychological and pharmacological options. Int J Womens Health. 2010;3:1-14.
Additional Reading
&NA;
  • Edinburgh Postnatal Depression Scale. http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.
  • Gjerdingen D, Katon W, Rich DE. Stepped care treatment of postpartum depression: a primary care-based management model. Womens Health Issues. 2008;18(1):44-52.
  • Harrington AR, Greene-Harrington CC. Healthy Start screens for depression among urban pregnant, postpartum and interconceptional women. J Natl Med Assoc. 2007;99(3):226-231.
  • Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician. 2010;82(8):926-933.
  • Howard LM, Boath E, Henshaw C. Antidepressant prevention of postnatal depression. PLoS Med. 2006;3(10):e389.
  • Kendall-Tackett K. A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Int Breastfeed J. 2007;2:6.
  • Musters C, McDonald E, Jones I. Management of postnatal depression. BMJ. 2008;337:a736.
  • Ng RC, Hirata CK, Yeung W, et al. Pharmacologic treatment for postpartum depression: a systematic review. Pharmacotherapy. 2010;30(9):928-941.
  • Sit DK, Wisner KL. Identification of postpartum depression. Clin Obstet Gynecol. 2009;52(3):456-468.
  • Tammentie T, Tarkka MT, Astedt-Kurki P, et al. Family dynamics and postnatal depression. J Psychiatr Ment Health Nurs. 2004;11(2):141-149.
Codes
&NA;
ICD10
  • F53 Puerperal psychosis
  • O90.6 Postpartum mood disturbance
Clinical Pearls
&NA;
  • PPD is a common, debilitating medical condition that impairs a mother's ability to function and interact with her infant and family.
  • Universal screening for depression is recommended during the 1st and 3rd trimester and at regular intervals during the postpartum period.
  • Early diagnosis and treatment are vital, as untreated PPD can lead to developmental difficulties for the infant and prolonged disability and suffering for the mother.
  • Breastfeeding is recommended for maternal and child health. Several medication options for treating depression in mothers are safe for breastfeeding infants.
  • Treatment with antidepressants should be individualized for breastfeeding mothers (4)[B].