This issue of eMedRef provides information to clinicians on the pathophysiology, diagnosis, and therapeutics of postpartum depression

Guo, James

University of Missouri: MOspace

Postpartum Depression Page 1 of 6    6.1.09   Postpartum Depression  See also Edinburgh Postnatal Depression Scale   Background  1. Definition  o Major depressive disorder (MDD) with postpartum onset o DSM IV defines onset within 4 weeks of birth o Onset may be during pregnancy or beyond first postpartum month   Must meet MDD criteria o Postpartum blues   Also called dysphoria or "baby blues"  Occurs in 15-85% of women  Occurs within 10 days of delivery with peak onset at 5 days  Lasts 1-14 days o Postpartum psychosis   More severe postpartum depression associated with confused thinking, mood swings, delusions, paranoia, disorganized behavior and poor judgment   Rapid onset in first 2-4 weeks after delivery  Most cases related to bipolar disorder, not schizophrenia 2. General information  o Similar in presentation and treatment to depression occurring at other times o Implications of the use of medications while breastfeeding and the known negative effects of maternal depression on infant development make identification and early intervention crucial o Maternal depressive symptoms at 2 weeks, 4 weeks, 6 months (but not at 14 months) associated with lower quality of mother -infant bonding  Pathophysiology 1. Incidence, prevalence  o Prevalence 5-10% at 4-8 weeks   Similar to general population of age-matched women o Incidence 3x rate of general population in first 5 weeks postpartum 2. Risk factors (SOR:B)  o Personal Hx of depression / mood disorder or other psychiatric disorder, especially postpartum (increases risk 30%) o Psychosocial stress (during and after pregnancy), especially repeated stress  o Family Hx of depression, inadequate social support o Prenatal   MDD or other mood disorders (anxiety)  Pregnancy loss (miscarriage or demise)  Lack of partner support o Intrapartum   Traumatic labor without adequate support o Postpartum   Postpartum blues  Hormonal fluctuations Postpartum Depression Page 2 of 6    6.1.09    Lack of psychosocial support  "Difficult"/ colicky baby / infant sleep problems  Immigrant status  Young maternal age / single mother  Domestic violence  Marital conflict  Poverty 3. Morbidity/ mortality  o Mother's health   Inadequate sleep, appetite to allow recovery from birth  Disruption of relationships  Suicide risk less than in general depressed population unless psychosis develops (up to 5%) o Infant's health   Failure to thrive  Excessive infant crying, colic, sleep problems, temperamental difficulties  Effect on infant neurodevelopment - poor cognitive functioning  Infanticide (rare, 8/100,000 live births, higher with maternal psychosis)   16-29% of women who kill their children also kill themselves o Up to 20% persistent depression o Psychosis occurs in 1/500 mothers o 80% resolve by 1 year postpartum  Diagnostics 1. History  o Mother's mood since delivery o Past or family history of mood disorders o Is mom able to enjoy baby, laugh, sleep when she has the opportunity? o Changes in appetite, libido, sleep, concentration outside of normal for postpartum period o Panic attacks o Feelings of being overwhelmed, unable to cope with parenting o Suicidal thoughts, thoughts of harming baby 2. Physical examination  o General condition, affect o Thought disorder o Thyroid 3. Diagnostic testing  o Hematocrit   Rule out anemia o TSH   Rule out thyroid disease o Edinburgh Postnatal Depression Scale    Most widely used  Modified 2 item patient health questionnaire and 3 item anxiety subscale of EPDS possibly effective screening tools o Postpartum Depression Screening Scale Postpartum Depression Page 3 of 6    6.1.09   4. Diagnostic criteria  o DSM IV criteria for major depressive episode, adjustment disorder with depressed mood o Postpartum qualifiers: DSM IV, onset within 4 weeks.  Differential Diagnosis  1. "Baby blues"  o Up to 85% of women have mood swings and tearfulness in first postpartum week o Do not interfere with ability to function, resolve by 1 week postpartum o If severe, more likely to persist or become postpartum depression 2. Thyroid disorders  o Up to 15% incidence of postpartum thyroiditis, usually self-limited 3. Anemia 4. Other psychiatric disorders:  o Dysthymia o Bipolar disorder o Schizoaffective disorder o Obsessive-compulsive disorder  Therapeutics 1. Acute treatment  o Assess for risk of   Suicidality  Harm to baby o Assess short-term social supports o Supportive counseling 2. Further management (24 hrs)  o If positive history, begin treatment of mood disorder immediately after delivery o Insufficient evidence to evaluate antenatal psychosocial assessment as method for reducing perinatal mental health morbidity o Mild PPD can be treated by non-mental health providers o Moderate-severe PPD and any psychosis should be referred o Psychotherapy (SOR:A)   Cognitive-behavioral therapy as effective as medication in mild to moderate postpartum depression  RCTs have shown that 12 sessions of Interpersonal Psychotherapy (IPT) are very effective for PPD  Psychodynamic therapy also useful for PPD  Psychotherapy in conjunction with medications has best outcomes   Breastfeeding mothers may prefer psychotherapy alone, still effective but less than combination therapy  Supportive therapy in conjunction with medications  Group therapy may be especially beneficial since it can help build social supports   Better for mild PPD or as more severe PPD responds to therapy  Postpartum Depression Page 4 of 6    6.1.09   o Medications (SOR:B)   In general   Use whatever medication has worked well for mother in the past, even if she is breastfeeding, monitor mother and infant for side effects  Non-breastfeeding mothers   Any effective drug that mother tolerates  Breastfeeding mothers   Start with the lowest dose and titrate up  Minimize exposure during peak breast milk levels  Watch for infant side effects  o Irritability, poor weight gain, sedation or change in feeding pattern  If infant side effects noted  o Reduce dose, change medication, partial or complete bottle feeding, consult lactation specialist  SSRIs/SNRIs   Paroxetine, sertraline  o Drugs of choice in breastfeeding mothers  Fluoxetine  o Less optimal during breastfeeding because of reported GI side effects (reversible) in breastfeeding infants  Other SSRIs and SNRIs probably safe  TCAs   Amitriptyline  o Only drug with reassuring long-term data on child development after breast milk exposure  Nortriptyline  o Undetectable infant serum levels  Nefazodone  o Elevated infant serum levels  Side effects limit use of most of these drugs, but good efficacy data  Other   MAO inhibitors  o Contraindicated in breastfeeding  St. John's Wort  o May be effective, probably safe in breastfeeding o Not FDA regulated so choice of product is more difficult o Electroconvulsive therapy may be used for severe or recalcitrant cases 3. Long-term care  o Watch for development of psychotic features o Follow every 1-2 weeks until stable, then every 1-2 months o Continue medication for at least 6 months, then taper if stable o Consider prophylactic medication postpartum in subsequent pregnancies    Postpartum Depression Page 5 of 6    6.1.09   Follow-Up 1. Return to office  o Time frame for return visit   No more than 1-2 weeks in acute treatment phase o Indications for earlier follow-up   Increasing symptoms or distress, inadequate short-term social supports 2. Refer to specialist  o Psychiatrist   If not improving, need help with medication choices or changes  Concern for psychosis or chronic psychiatric diagnosis such as schizophrenia 3. Admit to hospital  o Suicidal o Serious thoughts of harming infant if likely to be alone with infant and outpatient supervision by family member not possible o Evidence of psychosis o Support hospitalized breastfeeding mother to continue to feed baby or to have access to a hospital-grade double electric pump to maintain milk supply  Prognosis 1. Very good with early recognition and treatment  o Key to success is asking questions 2. Acute episode may resolve completely or may lead to chronic depression; recurrence/relapse common 3. Suicide risk 4. Recurrence risk with future pregnancies 50% 5. Untreated maternal depression may lead to cognitive, attention, and/or conduct disorders in the child  Prevention 1. Treatment of preexisting or prenatal depression or other mood disorders (anxiety, bipolar disorder) 2. Consider "prophylactic" antidepressant (sertraline, paroxetine or nortriptyline preferred) begun immediately postpartum for women with significant history of PPD 3. Adequate psychosocial supports in labor and postpartum by partner / spouse and family 4. Counseling does not prevent PPD, though it can treat the disorder   Evidence-Based Inquiry 1. Can counseling prevent or treat postpartum depression?  References 1. Hale, Thomas. Medications in Mothers' Milk, 11th edition. Pharmasoft Publishing, © 2004. 2. Misri S, Lusskin SI. Postpartum Blues and Depression. UpToDate online 13.1, © 2005, www.uptodateonline.com, accessed 6/8/2005.  Postpartum Depression Page 6 of 6    6.1.09   3. Bennett IM, Coco A, Coyne JC, etc. Efficiency of a two-item pre-screen to reduce the burden of depression screening in pregnancy and postpartum: an IMPLICIT network study. J Am Board Fam Med 2008 Jul-Aug;21(4):317 4. Blenning CE, Paladine H. An approach to the postpartum office visit. Am Fam Physician 2005; 72:2491-6, 2497-8 5. Daley AJ, Macarthur C, Winter H. The role of exercise in treating postpartum depression: a review of the literature. J Midwifery Womens Health 2007 01 Jan; 52(1):56-62 6. Dietz PM, Williams SB, Callaghan WM, etc. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry 2007 Oct;164(10):1515 7. Gavin NI, Gaynes BN, Lohr KN, etc. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 2005 Nov;106(5):1071 8. Halbreich U. The association between pregnancy processes, preterm delivery, low birth weight and postpartum depressions – the need for interdisciplinary integration. Am J Obstet Gynecol, 2005; 193: 1312-1322. 9. Kabir K, Sheeder J, Kelly LS. Identifying postpartum depression: are 3 questions as good as 10? Pediatrics 2008 Sep;122(3):e696 10. Moehler E, Brunner R, Wiebel A. Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother–child bonding, Arch Womens Ment Health 2006 Sep;9(5):273 11. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obset Gynecol, 2009 April; 357-364. 12. Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: a synthesis of the literature. Gen Hosp Psych 2004; 26:289-295.    Author:  James Guo, MD, LSU FMRP-Kenner, LA  Editor:  Robert Marshall, MD, MPH, Capt MC USN, Puget Sound Family Medicine Residence, Naval Hospital, Bremerton, WA       

Postpartum depression

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