Basics
Description
- Postpartum depression (PPD) is the most common medical complication after delivery.
- DSM-IV-TR defines PPD as the onset of depressive symptoms within the first 4 weeks following parturition.
- In clinical practice, however, it is not uncommon to consider the postpartum period up to 12 months following delivery.
Epidemiology
- Childbirth is a high-risk period for women to experience their first episode of a psychiatric disorder than any other time in their lives (1)[A].
- Postpartum blues or "maternity blues "
- Not considered a psychiatric disorder
- Estimated to occur in 15 " 85% of women within 1st week after delivery
- Postpartum depression
- Prevalence ranges from 10% to 20%
- Common within 6 " 12 weeks after parturition
- Postpartum psychosis
- Occurs in approximately 1 " 2 per 1,000 live births
- Rapid onset within 48 " 72 hours
- Although 75% of cases begin within first 2 weeks, risk remains high up to 6 months after delivery.
Prevalence
Reported prevalence rates of PPD vary depending on the defined period.
- 4.5 " 28% from 6 to 16 weeks, rates often peak at 12 weeks (1)[A]
Risk Factors
- Risk factors for postpartum blues and PPD
- History of premenstrual dysphoric disorder
- Previous history of depression or PPD
- Family history of depression
- Depression or anxiety during pregnancy
- Stressful negative life events
- Medically complicated pregnancy or delivery
- Unplanned pregnancy
- Adolescent mothers
- Inadequate or perceived limited social support
- Risk factors for postpartum psychosis
- History of bipolar disorder (25 " 50%) (1)[A]
- Previous postpartum psychosis
- Primiparity
General Prevention
- Shame, stigma, perception as a bad mother, or fear that children may be taken away prevent women from seeking treatment in a timely manner.
- Women are more likely to seek help from their primary care physician or obstetricians rather than mental health professionals.
- Pregnant women who experience anxiety or depression should be closely monitored prenatally and are at greater risk after delivery.
- Screening women in routine prenatal and postpartum checks as well as well-baby visits.
- It is important to ask about their mood and feelings toward their child and to refer to mental health professional for further evaluation.
- Administer the Edinburgh Postnatal Depression Scale (EPDS), a self-report 10-item scale that is specific for PPD.
Etiology
Unclear etiology
- Numerous theories implicate the hypothalamic " pituitary " gonadal axis of fluctuating hormonal levels with inconclusive data.
- Current hypothesis is that some women have an inherent neuroendocrine sensitivity to psychological, environmental, and physiologic factors, which is triggered by the onset of menarche, increasing their risk to mood dysregulation during their reproductive years (2)[B].
Associated Conditions
Thyroid dysfunction " in the 6 months following delivery, women experience thyroid dysfunction at rates of up to 10%.
Diagnosis
History
- Postpartum blues
- Onset within 2 weeks and peaks 4 or 5 days after delivery (2)[B]
- Considered to be a "normal " physiologic response to the hormonal events of childbirth
- Symptoms include labile mood, tearfulness, anxious mood, irritability, elation, poor concentration, insomnia, hypersensitivity.
- Symptoms are typically self-remitting but 20% of women can develop depressive symptoms.
- Postpartum depression
- Usually presents within 6 " 12 weeks to 1st year after delivery
- Resembles major depressive episode
- Sleep disturbance, particularly inability to return to sleep after feeding baby or when infant is asleep
- Labile mood with prominent anxiety and irritability
- Mild hypomanic symptoms can be observed in the 1st week and 50% of these women developed PPD at 6 wks (1)[A].
- Overanxious, overwhelmed, or unable to take care of baby
- Feelings of inadequacy or failure as a mother
- Frequent calls or visits about own health or baby 's without objective reasoning and inability to be reassured
- Distressing, intrusive, aggressive thoughts or images of the infant being harmed with or without compulsions
- Suicidal ideation
- Postpartum psychosis
- Usually presents within the first 48 " 72 hours with rapid progression in the first 2 " 4 weeks after delivery (1)[B]
- Delusional beliefs include religious themes, often pertaining to the baby (infant is possessed or has special powers) or self.
- Hypervigilance about the baby
- Insomnia and psychomotor hyperkinesias
- Perplexed, confused, or disoriented
- Bizarre behavior
- Impaired cognition or delirium-like symptoms with waxing and waning course
- Visual, auditory, olfactory, or tactile hallucinations have been reported and can include commands to harm self or child.
- Risk of infanticide and suicide are high
Physical Exam
- Medical work-up should be initiated to rule out organic etiologies, such as:
- Thyroid abnormalities
- Sheehan 's syndrome
- Pregnancy-related autoimmune disorders
- Intracranial mass
- Anemia
- Studies that implemented screening protocols have reported increased rates of detection.
- EPDS can aid in early detection. Score >12 is indicative of probable PPD.
- The scale may be obtained on the internet: http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
Tests
Lab
Imaging
Consider MRI if suspicion of intracranial mass or Sheehan 's syndrome
Differential Diagnosis
- Thyroid abnormalities
- Sheehan 's syndrome
- Pregnancy-related autoimmune disorders
- Intracranial mass
- Anemia
- Illicit drug use
Treatment
Most successful treatment strategies are multifactorial, including:
- Education for women and their families
- Psychotherapy
- Group support
- Referrals to self-help and national organizations
- Involvement of spouse and/or family members
- Psychopharmacological management, if appropriate for moderate-to-severe depression with a minimum of 6 months duration
- Inpatient hospitalization
Medication
- Patients should be informed about limitations on current data (small sample size, case studies, and imperfect FDA categories).
- No medication should be used without discussing risks and benefits with both patient and her partner.
- Little is known in terms of risks of long-term neurobehavioral sequelae after exposure to psychotropic medications in a developing brain vs. the risk of untreated depression for the patient and infant.
- Data on the use of hormonal agents is limited.
First Line
Sertraline: Starting dose 25 mg/day (3)[A]
Second Line
- Nortriptyline: Starting dose 25 mg/day (3)[B]
- Paroxetine: Starting dose 10 mg/day (3)[B]
- Fluoxetine: Starting dose 10 mg/day for non-breastfeeding women. Fluoxetine has higher levels of secretion in breast milk (2)[B].
For breastfeeding mothers:
- FDA has not approved any antidepressant for use during lactation.
- Psychotropic medications are excreted in breast milk.
- Nursing mothers should be prescribed the minimum dosage to achieve a symptom reduction.
- Taking medication immediately after breastfeeding minimizes the amount present in milk and maximizes clearance before the next feeding.
- Short-acting agents are preferable to long-acting agents.
- Bottle-feeding supplementation is encouraged to minimize drug exposure.
- Assessment by pediatrician should be made to establish baseline behavior, sleep, and feeding patterns.
- Infant drug clearance increases from nearly 33% of mother 's weight-adjusted clearance to 100% by 6 months of age.
- For premature infants, liver enzymes are immature and drug clearance is slow; psychiatric medication levels may accumulate and adversely affect the infant.
- Among the SSRIs, sertraline and paroxetine have nondetectable serum levels in breastfed infants (3)[B].
- Nortriptyline levels are nonquantifiable in breastfed infants.
- Up to 30% of infants with SSRI exposure in utero have been associated with neonatal withdrawal symptoms which can persist 10 days after birth (2)[B].
Additional Treatment
General Measures
- Postpartum blues
- Women generally respond to education, support, and reassurance that symptoms typically remit within 2 weeks after delivery.
- Postpartum depression
- Women with mild-to-moderate depression usually are responsive to reduction of psychological stressors, mobilization of family/partner support, individual or group therapy, and self-help groups.
- Women with severe depressive symptoms or functional impairment in their daily life should discuss antidepressant medication use with their clinician.
- Decision to use medications should take into consideration whether the patient is breastfeeding.
- Hospitalization if suicidal
- Electroconvulsive therapy (ECT)
- Postpartum psychosis
- Psychiatric hospitalization is almost always indicated as risk for neglect of the child, infanticide, and suicide is high.
- Mood stabilizers
- Neuroleptics
- Antidepressants
- Benzodiazepines
- ECT
Issues for Referral
- Assessment by pediatrician should be made to establish baseline behavior, sleep, and feeding patterns prior to initiation of psychotropic medications in breastfed infants.
- Nursing mothers should be referred to mental health providers and closely monitored by the physician.
Complementary and Alternative Medicine
Light therapy, exercise, SAMe, folic acid, and omega-3 fatty acids are promising alternatives for women with mild symptoms or as adjunctive treatments (4)[C].
Ongoing Care
Prognosis
- Prompt detection and treatment for these women is imperative in the overall impact on the mother " infant attachment and bonding.
- Untreated depression has consistently shown adverse outcomes in social, emotional, and behavioral development in children of depressed mothers.
- The longer duration of untreated symptoms in women may prolong total recovery once treatment is undertaken.
Complications
- Women with prior history of PPD have a 50% recurrence with each subsequent delivery and are prone to 25% risk in having non-postpartum episodes.
- A previous history of depression is associated with a 25% risk of depression after delivery (2)[B].
- A previous postpartum psychosis is associated with 20 " 50% risk of relapse following subsequent deliveries (1)[B].
- Women with a history of bipolar disorder and postpartum psychosis have a 50% risk of relapse with each successive delivery.
- Risk of suicide is 4% in women who experience postpartum psychosis (1)[B].
References
1Doucet S, Dennis C-L, Letourneau N. Differentiation and clinical implications of postpartum depression and postpartum psychosis. J Obstet Gynecol Neonatal Nurs. 2009;38(3):269 " 279. [View Abstract]2Muzik M, Marcus SM, Heringhausen JE. When depression complicates childbearing: Guidelines for screening and treatment during antenatal and postpartum obstetric care. Obstet Gynecol Clin N Am. 2009;36(4):771 " 788. [View Abstract]3Di Scalea TL, Wisner KL. Pharmacotherapy of postpartum depression. Expert Opin Pharmacother. 2009;10(16):2593 " 2607. [View Abstract]4Freeman MP, Fava M, Lake J. Complementary and alternative medicine in major depressive disorders: The American Psychiatric Association task-force report. J Clin Psychiatry. 2010;71(6):669 " 681. [View Abstract]
Additional Reading
1 Diagnostic and statistical manual of mental disorders (DSM-IV), 4th ed. Washington, DC: American Psychiatric Publishing, 1994.2Blom EA, Jansen PW, Verhulst FC. Perinatal complications increase the risk of postpartum depression: The generation R study. BJOG. 2010;117:1390 " 1398. [View Abstract]3 Drug Registries. www.fda.gov4Flynn HA. Epidemiology and phenomenology of postpartum mood disorders. Psych Annals. 2005;35(7):544 " 551.5Pearlstein T, Howard M, Salisbury A. Postpartum depression. Am J Obstet Gynecol. 2009;200(4):357 " 364. [View Abstract]6 Postpartum Support International. www.postpartum.net7www.mededppd.org8www.motherrisk.org9www.womensmentalhealth.org
Codes
ICD9
- 648.40 Mental disorders of mother, unspecified as to episode of care or not applicable
- 648.41 Mental disorders of mother, delivered, with or without mention of antepartum condition
- 648.43 Mental disorders of mother, antepartum condition or complication
- 648.44 Mental disorders of mother, postpartum condition or complication
- 311 Depressive disorder, not elsewhere classified
ICD10
F53 Puerperal psychosis
SNOMED
- 58703003 postpartum depression (disorder)
- 25922000 major depressive disorder, single episode with postpartum onset (disorder)
- 279225001 maternity blues (disorder)
- 237349002 mild postnatal depression (disorder)
- 237350002 severe postnatal depression (disorder)
Clinical Pearls
- Postpartum blues is a self-limited disorder involving mild depressive symptoms which typically remit 2 weeks after delivery.
- Postpartum depression (PPD) affects up to 10 " 20% of mothers yet is under-recognized and undertreated.
- Postpartum psychosis is considered to be a psychiatric emergency requiring hospitalization as the risks for child neglect, infanticide, and maternal suicide are high.