Postpartum Depression

Primer

Postpartum Depression (PPD) (also known as Peripartum Depression) is an episode of major depression 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. PPD affects 10% to 15% of women who have recently given birth.

Peripartum

50% percent of “postpartum” major depressive episodes in fact begin prior to delivery. These episodes are defined as peripartum episodes.

"Baby Blues"

The “Baby Blues” are symptoms of 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.

Effect on offspring

Persistence of maternal depression can increase the risk of children developing emotional problems including anxiety, disruptive disorders, and depressive disorders, while remission of depression has a positive effect on both mothers and their children.

Risk Factors

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.

Psychosis

Postpartum mood (major depressive or manic) episodes with psychotic features occur from 1 in 500 to 1 in 1,000 deliveries and may be more common in primiparous women. Psychotic features is increased for women with previous postpartum mood episodes, a prior history of a depressive or bipolar disorder (especially bipolar I disorder) and those with a family history of bipolar disorders.

Diagnostic Criteria

The diagnosis of postpartum depression is the same the diagnostic criteria for Major Depressive Disorder (MDD), except that the onset of symptoms are during the course of pregnancy or up to 4 weeks after delivery.

Note: Mood episodes can have their onset either during pregnancy or postpartum. Although the estimates differ according to the period of follow-up after delivery, between 3% and 6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery. 50% of “postpartum” major depressive episodes actually begin prior to delivery. Thus, these episodes are referred to collectively as peripartum episodes. Women with peripartum major depressive episodes often have severe anxiety and even panic attacks. Prospective studies have demonstrated that mood and anxiety symptoms during pregnancy, as well as the “baby blues,” increase the risk for a postpartum major depressive episode.

Peripartum-onset mood episodes can present either with or without psychotic features. Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but psychotic symptoms can also occur in severe postpartum mood episodes without such specific delusions or hallucinations. Postpartum mood (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common in primiparous women. The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of a depressive or bipolar disorder (especially bipolar I disorder) and those with a family history of bipolar disorders.

Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a fluctuating level of awareness or attention. The postpartum period is unique with respect to the degree of neuroendocrine alterations and psychosocial adjustments, the potential impact of breast-feeding on treatment planning, and the long-term implications of a history of postpartum mood disorder on subsequent family planning.

Scales

Psychometric Scales for Postpartum Depression

Name Rater Description Download
Edinburgh Postnatal Depression Scale (EPDS) Patient/Clinician The EPDS is a 10-question screening questionnaire (not diagnostic) to assess for symptoms of depression and anxiety during pregnancy and in the year following the birth of a child. EPDS Download

Pathophysiology

Hormonal

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.[1]

Autoimmune

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.

Differential Diagnosis

  • Baby blues
    • Generally appear within 3 to 4 days after delivery, peak on the postpartum day 7, and disappear within 2 weeks.
  • 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[2]
  • Iron deficiency
    • Low serum ferritin and postpartum depression are also strongly associated.[3]

Treatment

Psychotherapy

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

Pharmacotherapy

See main article: Obstetric and Fetal Pharmacology

The risks of untreated depression during pregnancy are significant and well-documented, while the risks associated with antidepressant exposure are less clear. To date, there is no definitive study linking antidepressant use in pregnancy to autism or any other significant abnormality in the newborn. Pregnant women with depression should be assessed and given the best treatment possible based on that assessment, 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.

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References

1) Schiller, C. E., Meltzer-Brody, S., & Rubinow, D. R. (2015). The role of reproductive hormones in postpartum depression. CNS spectrums, 20(1), 48-59.
2) Mestman, J. H. (1997). Evaluating and Managing Postpartum Thyroid Dysfunction. Medscape women's health, 2(7), 3-3.
3) Albacar, G., Sans, T., Martín-Santos, R., García-Esteve, L., Guillamat, R., Sanjuan, J., ... & Gaviria, A. (2011). An association between plasma ferritin concentrations measured 48 h after delivery and postpartum depression. Journal of affective disorders, 131(1), 136-142.