Peripartum and Postpartum Depression

Postpartum Depression (PPD) (also known as Peripartum Depression, or Major Depressive Disorder with peripartum onset in the DSM-5) is a subtype of depression that occurs during pregnancy or in the first 4 weeks after delivery. However, women remain at risk for developing depression up to several months following delivery. PPD is the most common psychiatric complication related to child-bearing.

• The change from DSM-IV's “postpartum depression” to DSM-5's “peripartum onset” reflects evidence that 50% of postpartum depression episodes actually occur prior to delivery.^[1]

• Prevalence is between 10-22% of adult women (average 15%), including minor depressive episodes
  • There are higher rates in adolescent mothers (26-53%)
• 60% of women have their first depressive episode in the postpartum period

• Perinatal maternal depression is associated with many adverse outcomes in the offspring, including worse obstetrical outcomes, neonatal intensive care admissions, increased neonatal complications, and developmental delay, difficulty with emotional regulation, behavioural disorders, and attachment issues in the offspring.^[2]
• Remission of depression, on the other hand, has a positive effect on both mothers and their children.

• Anxiety disorders, obsessive‐compulsive disorder, and substance use disorders are common comorbidities.

• Risk factors include previous depression during pregnancy, anxiety during pregnancy, stressful life events during pregnancy or the early puerperium, low levels of social support, or a personal or family history of depression.
• Women with a history of postpartum depression are also at increased risk of recurrence.

The diagnosis of postpartum depression is the same the diagnostic criteria for major depressive disorder, except that the onset of symptoms are during the course of pregnancy or up to 4 weeks after delivery.

• Postpartum depression can present either with or without psychotic features. If there are psychotic symptoms, it is important to note that infanticide is associated with postpartum psychotic episodes (mothers may experience command hallucinations to kill the infant or delusions that the infant is possessed).
• Psychotic symptoms can also occur in severe postpartum mood episodes without specific delusions or hallucinations involving the infant.

• The onset of depressive symptoms is temporally coincident with the rapid changes in estradiol and progesterone levels that occur at delivery. Alterations in the immune system, HPA axis, and lactogenic hormones also contribute to the pathophysiology of PPD.^[3]

• Alterations in tryptophan metabolism, due to the increase in monoamine oxidase A (MAO-A) levels, are also thought to be a potential factor in postpartum depression.^[4] Small size studies have found that dietary supplementation with tryptophan and tyrosine in the early postpartum period reduce vulnerability to depressive symptoms.^[5]

• Co-existing autoimmune disorders may also be exacerbated during the postpartum period. For individuals at high risk or with a prior history of thyroid disorders, a work up including TSH and T4 should be done.

• Baby blues
  • Generally appear within 3 to 4 days after delivery, peak on the postpartum day 7, and disappear within 2 weeks. Symptoms are mainly mood lability, tearfulness, anxiety, insomnia, and irritability that do not meet the full criteria for depression. Since these are mild and transient symptoms, no treatment is required. The baby blues affect 30% to 75% of women shortly after childbirth. The “Blues” may sometimes be the early manifestation of postpartum depression or puerperal psychosis.
• Anxiety disorders and obsessive–compulsive disorder
  • These disorders are also common in the postpartum period and need to be differentiated from postpartum depression.
• Autoimmune thyroid disorders and hypothyroidism
  • Can mimic symptoms of postpartum depression and can affect the clinical response to antidepressants. A work up should be done in high risk individuals^[6]
• Iron deficiency
  • Low serum ferritin and postpartum depression are also strongly associated.^[7]
• Delirium
  • Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a fluctuating level of awareness or attention.

• Cognitive behavioural therapy and interpersonal psychotherapy should always be considered first for mild to moderate depression and anxiety during pregnancy.

• Pregnant women with depression should be assessed and given the best treatment possible based on clinical assessment of the risks and benefits, which includes the use of antidepressants if indicated.
  • The rate of relapse is high in females with recurrent depression who stop their antidepressant during pregnancy.
  • In severe postpartum depression, pharmacotherapy (first-line medications are escitalopram, citalopram, and sertraline) is recommended over psychotherapy. This is because the risks of untreated depression during pregnancy are significant and well-documented, while the risks associated with antidepressant exposure remain poorly understood.
  • To date, there is no definitive study linking antidepressant use in pregnancy to autism, but associations have been reported.^[9]
  • However, paroxetine and clomipramine are associated with increased risk for fetal cardiovascular malformations, and should only be used if there is a clear, cogent, and compelling reason to use.^[10]
  • Additionally, doxepin should not be used due to high expression into breast milk and fetal complicayions
  • MAOIs are also not recommended due to the risk of interaction with anesthesia.^[11]
• The main risks and adverse events that clinicians should discuss with their patients is as follows:
  • There is an association between SSRI use and increased risk for spontaneous abortions, and reduced birth weight.^[12]
  • At the time of delivery, fetuses exposed to SSRIs in the 3rd trimester are at increased risk for developing neonatal adaptation syndrome (NAS), which is a syndrome that consists of jitteriness, irritability, respiratory distress, tremors, and excessive crying.^[13]
    • The prevalence of this is as high as 30% of infants, and is mostly self-limiting and resolves in 2 to 14 days.
  • Other risks include persistent pulmonary hypertension (PPH), which is estimated to double the risk compared to the general population (i.e. risk increases from 2 per 1,000, to 2.9 to 3.5 per 1,000).

• Electroconvulsive therapy (ECT) is a safe and effective treatment for severe depression in pregnant women, and may be used when antidepressant medications are unsuccessful.

• Breastfeeding while on antidepressant medication is not contraindicated, though there are certain medications that one should avoid.^[14]