- Last edited on April 30, 2020
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mood:1-depression:postpartum-peripartum [on April 30, 2020] |
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| - | ====== Postpartum Depression ====== | + | ====== Peripartum and Postpartum Depression ====== |
| {{INLINETOC}} | {{INLINETOC}} | ||
| ===== Primer ===== | ===== Primer ===== | ||
| - | **Postpartum Depression (PPD)** (also known as **Peripartum Depression**) is an episode of [[mood:1-depression:home|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. | + | **Postpartum Depression (PPD)** (also known as **Peripartum Depression**, or **Major Depressive Disorder with peripartum onset** in the DSM-5) is a subtype of [[mood:1-depression:home|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. |
| - | ==== Peripartum ==== | + | == History == |
| - | 50% percent of “postpartum” major depressive episodes in fact begin prior to delivery. These episodes are defined as peripartum episodes. | + | * 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.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] |
| - | ==== "Baby Blues" ==== | + | == Epidemiology == |
| - | 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. | + | * 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 | ||
| - | == Effect on offspring == | + | == Prognosis == |
| - | 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. | + | * Perinatal maternal depression is associated with many adverse outcomes in the offspring, including worse obstetrical outcomes, neonatal intensive care admissions, increased neonatal complications, and [[child:motor:developmental-coordination|developmental delay]], difficulty with emotional regulation, behavioural disorders, and [[child:attachment:home|attachment issues]] in the offspring.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994788/|MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] |
| - | + | * Remission of depression, on the other hand, has a positive effect on both mothers and their children. | |
| - | <WRAP group> | + | |
| + | == Comorbidity == | ||
| + | * [[anxiety:home|Anxiety disorders]], [[ocd:1-ocd|obsessive‐compulsive disorder]], and [[addictions:home|substance use disorders]] are common comorbidities. | ||
| - | <WRAP half column> | ||
| == Risk Factors == | == 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. | + | * 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. |
| - | </WRAP> | + | * Women with a history of postpartum depression are also at increased risk of recurrence. |
| - | <WRAP half column> | + | ===== Specifier Criteria ===== |
| - | == Psychosis == | + | The diagnosis of postpartum depression is the same the diagnostic criteria for [[mood:1-depression:home|major depressive disorder]], except that the onset of symptoms are during the course of pregnancy or up to ''4'' weeks after delivery. |
| - | 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. | + | ===== Postpartum Psychosis ===== |
| - | </WRAP> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| - | </WRAP> | + | See main article: **[[psychosis:z-postpartum|]]** |
| - | ===== Diagnostic Criteria ===== | + | </alert> |
| - | The diagnosis of postpartum depression is the same the diagnostic criteria for [[mood:1-depression:home|]], except that the onset of symptoms are during the course of pregnancy or up to ''4'' weeks after delivery. | + | |
| - | <callout> | + | * 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). |
| - | **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. | + | * Psychotic symptoms can also occur in severe postpartum mood episodes without specific delusions or hallucinations involving the infant. |
| - | \\ \\ | + | |
| - | 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. | + | |
| - | </callout> | + | |
| ===== Scales ===== | ===== Scales ===== | ||
| <panel title="Psychometric Scales for Postpartum Depression" no-body="true"> | <panel title="Psychometric Scales for Postpartum Depression" no-body="true"> | ||
| - | !^! Name ^ Rater ^ Description ^ Download ^ | + | <mobiletable 1> |
| + | ^ 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. | {{ :mood:edinburgh_perinatal_postnatal_depression_scale_epds_.pdf |EPDS 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. | {{ :mood:edinburgh_perinatal_postnatal_depression_scale_epds_.pdf |EPDS Download}} | | ||
| + | </mobiletable> | ||
| </panel> | </panel> | ||
| ===== Pathophysiology ===== | ===== Pathophysiology ===== | ||
| ==== Hormonal ==== | ==== 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.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363269/|Schiller, C. E., Meltzer-Brody, S., & Rubinow, D. R. (2015). The role of reproductive hormones in postpartum depression. CNS spectrums, 20(1), 48-59.]])] | + | * 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.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363269/|Schiller, C. E., Meltzer-Brody, S., & Rubinow, D. R. (2015). The role of reproductive hormones in postpartum depression. CNS spectrums, 20(1), 48-59.]])] |
| + | |||
| + | ==== Metabolism ==== | ||
| + | * 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.[([[https://pubmed.ncbi.nlm.nih.gov/29307018/|Duan, K. M., Ma, J. H., Wang, S. Y., Huang, Z., Zhou, Y., & Yu, H. (2018). The role of tryptophan metabolism in postpartum depression. Metabolic brain disease, 33(3), 647-660.]])] Small size studies have found that dietary supplementation with tryptophan and tyrosine in the early postpartum period reduce vulnerability to depressive symptoms.[([[https://pubmed.ncbi.nlm.nih.gov/28289215/|Dowlati, Y., Ravindran, A. V., Segal, Z. V., Stewart, D. E., Steiner, M., & Meyer, J. H. (2017). Selective dietary supplementation in early postpartum is associated with high resilience against depressed mood. Proceedings of the National Academy of Sciences, 114(13), 3509-3514.]])] | ||
| ==== Autoimmune ==== | ==== Autoimmune ==== | ||
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[cl:thyroid-disorders|]]**</alert> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| - | 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. | + | See also: **[[cl:thyroid-disorders|]]** |
| + | </alert> | ||
| + | |||
| + | * 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 ===== | ===== Differential Diagnosis ===== | ||
| * **Baby blues** | * **Baby blues** | ||
| - | * Generally appear within ''3'' to ''4'' days after delivery, peak on the postpartum day 7, and disappear within ''2'' weeks. | + | * 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:home|Anxiety disorders]]** and **[[ocd:1-ocd|obsessive–compulsive disorder]]** | * **[[anxiety:home|Anxiety disorders]]** and **[[ocd:1-ocd|obsessive–compulsive disorder]]** | ||
| * These disorders are also common in the postpartum period and need to be differentiated from postpartum depression. | * These disorders are also common in the postpartum period and need to be differentiated from postpartum depression. | ||
| - | * **[[cl:thyroid-disorders|Autoimmune thyroid disorders]]** and **[[cl:thyroid-disorders:hypothyroidism|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[([[https://www.medscape.com/viewarticle/719255_2|Mestman, J. H. (1997). Evaluating and Managing Postpartum Thyroid Dysfunction. Medscape women's health, 2(7), 3-3.]])] | + | * **[[cl:thyroid-disorders|Autoimmune thyroid disorders]]** and **[[cl:thyroid-disorders:hypothyroidism|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[([[https://www.medscape.com/viewarticle/719255_2|Mestman, J. H. (1997). Evaluating and Managing Postpartum Thyroid Dysfunction. Medscape women's health, 2(7), 3-3.]])] | ||
| * **Iron deficiency** | * **Iron deficiency** | ||
| * Low serum ferritin and postpartum depression are also strongly associated.[([[https://www.ncbi.nlm.nih.gov/pubmed/21130499|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.]])] | * Low serum ferritin and postpartum depression are also strongly associated.[([[https://www.ncbi.nlm.nih.gov/pubmed/21130499|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.]])] | ||
| + | * **[[cl:1-delirium|Delirium]]** | ||
| + | * Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a fluctuating level of awareness or attention. | ||
| + | |||
| ===== Treatment ===== | ===== Treatment ===== | ||
| + | <panel type="info" title="Treatment of Mild to Moderate Major Depressive Disorder during Pregnancy" subtitle="MacQueen, G. M. et al. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603." no-body="true" footer=""> | ||
| + | ^ 1st line | **Monotherapy**: [[psychotherapy:cbt|cognitive behavioural therapy (CBT)]], [[psychotherapy:ipt|interpersonal psychotherapy (IPT)]] (individual or group) | | ||
| + | ^ 2nd line | **Monotherapy**: [[meds:antidepressants:ssri:citalopram|citalopram]], [[meds:antidepressants:ssri:escitalopram|escitalopram]], [[meds:antidepressants:ssri:sertraline|sertraline]]\\ **Combination therapy**: combination [[meds:antidepressants:ssri:home|SSRI]] + [[psychotherapy:cbt|CBT]] or [[psychotherapy:ipt|IPT]] | | ||
| + | ^ 3rd line (in order of evidence) | • Structured [[teaching:exercise-prescription|exercise]], acupuncture (depression specific), [[teaching:phototherapy|bright-light therapy]]\\ • [[meds:antidepressants:ndri:bupropion|Bupropion]], [[meds:antidepressants:snri:v-desvenlafaxine|desvenlafaxine]], [[meds:antidepressants:snri:duloxetine|duloxetine]], [[meds:antidepressants:ssri:fluoxetine|fluoxetine]], [[meds:antidepressants:ssri:fluvoxamine|fluvoxamine]], [[meds:antidepressants:nassa:mirtazapine|mirtazapine]], [[meds:antidepressants:tca:home|TCAs]] (caution with [[meds:antidepressants:tca:clomipramine|clomipramine]] due to risk of cardiac malformations!), [[meds:antidepressants:snri:venlafaxine|venlafaxine]]\\ • [[brain-stimulation:ect|Electroconvulsive therapy]] (for severe, psychotic, or treatment-resistant depression)\\ • Therapist-assisted Internet [[psychotherapy:cbt|CBT]], [[psychotherapy:mindfulness|mindfulness-based]] CBT, [[psychotherapy:supportive|supportive psychotherapy]], couples therapy, [[psychotherapy:psychodynamic:home|psychodynamic psychotherapy]], [[brain-stimulation:rtms|rTMS]]\\ • Combination [[meds:antidepressants:ssri:home|SSRI]] + CBT or IPT | | ||
| + | </panel> | ||
| ==== Psychotherapy ==== | ==== Psychotherapy ==== | ||
| - | Cognitive behavioural therapy and interpersonal psychotherapy should always be considered first for mild to moderate depression and anxiety during pregnancy. | + | * Cognitive behavioural therapy and interpersonal psychotherapy should always be considered first for mild to moderate depression and anxiety during pregnancy. |
| ==== Pharmacotherapy ==== | ==== Pharmacotherapy ==== | ||
| - | <callout type="success">{{fa>arrow-circle-right?color=green}} See main article: **[[meds:pharmacology:obstetric-and-fetal]]**</callout> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| + | See also article: **[[meds:pharmacology:obstetric-and-fetal]]** | ||
| + | </alert> | ||
| - | 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. | + | <callout type="question" title="How Long Should Antidepressant Use Continue?" icon="true"> |
| + | Based on recommendations and studies from the general adult population, it is recommended that women for low risk of relapse remain on antidepressants for another 6 to 12 months after achieving remission of symptoms.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994788/|MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] | ||
| + | </callout> | ||
| + | |||
| + | * 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 [[meds:antidepressants:ssri:escitalopram|escitalopram]], [[meds:antidepressants:ssri:citalopram|citalopram]], and [[meds:antidepressants:ssri:sertraline|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.[([[https://pubmed.ncbi.nlm.nih.gov/32375539/|Vega, M. L., Newport, G. C., Bozhdaraj, D., Saltz, S. B., Nemeroff, C. B., & Newport, D. J. (2020). Implementation of advanced methods for reproductive pharmacovigilance in autism: a meta-analysis of the effects of prenatal antidepressant exposure. American Journal of Psychiatry, 177(6), 506-517.]])] | ||
| + | * However, [[meds:antidepressants:ssri:paroxetine|paroxetine]] and [[meds:antidepressants:tca:clomipramine|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.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994788/|MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] | ||
| + | * Additionally, [[meds:antidepressants:tca:doxepin|doxepin]] should not be used due to high expression into breast milk and fetal complicayions | ||
| + | * [[meds:antidepressants:maoi:home|MAOIs]] are also not recommended due to the risk of interaction with anesthesia.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994788/|MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] | ||
| + | * 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.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994788/|MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] | ||
| + | * 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.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994788/|MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] | ||
| + | * 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). | ||
| ==== ECT ==== | ==== ECT ==== | ||
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[brain-stimulation:ect|]]**</alert> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| + | See also: **[[brain-stimulation:ect|]]** | ||
| + | </alert> | ||
| + | |||
| + | * 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 ==== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See also article: **[[meds:pharmacology:obstetric-and-fetal|]]** | ||
| + | </alert> | ||
| + | |||
| + | * Breastfeeding while on antidepressant medication is not contraindicated, though there are certain medications that one should avoid.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994788/|MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] | ||
| + | |||
| + | <panel type="info" title="Treatment of Mild to Moderate Postpartum Depression during Breastfeeding" subtitle="MacQueen, G. M. et al. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603." no-body="true" footer=""> | ||
| + | ^ 1st line | **Monotherapy**: [[psychotherapy:cbt|cognitive behavioural therapy (CBT)]], [[psychotherapy:ipt|interpersonal psychotherapy (IPT)]] (individual or group) | | ||
| + | ^ 2nd line | **Monotherapy**: [[meds:antidepressants:ssri:citalopram|citalopram]], [[meds:antidepressants:ssri:escitalopram|escitalopram]], [[meds:antidepressants:ssri:sertraline|sertraline]]\\ **Combination therapy**: combination [[meds:antidepressants:ssri:home|SSRI]] + CBT or IPT | | ||
| + | ^ 3rd line | • Structured [[teaching:exercise-prescription|exercise]], acupuncture (depression specific), therapist-assisted Internet [[psychotherapy:cbt|CBT]], or behavioural activation\\ • [[meds:antidepressants:ssri:fluoxetine|Fluoxetine]], [[meds:antidepressants:ssri:fluvoxamine|fluvoxamine]], [[meds:antidepressants:ssri:paroxetine|paroxetine]], [[meds:antidepressants:tca:home|TCAs]] (except [[meds:antidepressants:tca:doxepin|doxepin]], do not use!)\\ • [[meds:antidepressants:ndri:bupropion|Bupropion]], [[meds:antidepressants:snri:v-desvenlafaxine|desvenlafaxine]], [[meds:antidepressants:snri:duloxetine|duloxetine]], [[meds:antidepressants:nassa:mirtazapine|mirtazapine]], [[meds:antidepressants:snri:venlafaxine|venlafaxine]], [[brain-stimulation:rtms|rTMS]], [[teaching:phototherapy|bright-light therapy]]\\ • [[brain-stimulation:ect|Electroconvulsive therapy (ECT)]] (for severe, psychotic, or treatment-resistant depression)\\ • [[psychotherapy:mindfulness|Mindfulness-based]] CBT, [[psychotherapy:supportive|supportive psychotherapy]], couples therapy, [[psychotherapy:psychodynamic:home|psychodynamic psychotherapy]] | | ||
| + | </panel> | ||
| + | |||
| + | ===== Guidelines ===== | ||
| + | {{page>teaching:clinical-practice-guidelines-cpg#perinatal&nouser&noheader&nodate&nofooter}} | ||
| ===== Resources ===== | ===== Resources ===== | ||
| Line 76: | Line 127: | ||
| <WRAP group> | <WRAP group> | ||
| <WRAP quarter column> | <WRAP quarter column> | ||
| - | ==== For Patients ==== | + | == For Patients == |
| </WRAP> | </WRAP> | ||
| <WRAP quarter column> | <WRAP quarter column> | ||
| - | ==== For Providers ==== | + | == For Providers == |
| + | * **[[https://www.nature.com/articles/nrdp201822|Meltzer-Brody, S. et al. (2018). Postpartum psychiatric disorders. Nature reviews Disease primers, 4(1), 1-18.]]** | ||
| * [[http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/MentalHealthDisordersGuideline.pdf|Best Practice Guidelines for Perinatal Mental Health Disorders - Perinatal Services BC]] | * [[http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/MentalHealthDisordersGuideline.pdf|Best Practice Guidelines for Perinatal Mental Health Disorders - Perinatal Services BC]] | ||
| + | * [[http://ncrptraining.org/|National Curriculum Reproductive Psychiatry]] | ||
| * [[http://www.jogc.com/article/S1701-2163(16)35240-9/fulltext|Postpartum Depression: Diagnostic and Treatment Issues]] | * [[http://www.jogc.com/article/S1701-2163(16)35240-9/fulltext|Postpartum Depression: Diagnostic and Treatment Issues]] | ||
| * [[http://www.rxfiles.ca/rxfiles/uploads/documents/Antidepressants-PregnancyandBreastfeeding-QandA.pdf|Are Antidepressants Safe during Pregnancy & Breastfeeding? - RxFiles]] | * [[http://www.rxfiles.ca/rxfiles/uploads/documents/Antidepressants-PregnancyandBreastfeeding-QandA.pdf|Are Antidepressants Safe during Pregnancy & Breastfeeding? - RxFiles]] | ||
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| <WRAP quarter column> | <WRAP quarter column> | ||
| == Research == | == Research == | ||
| - | * [[http://www.camh.ca/en/hospital/about_camh/newsroom/news_releases_media_advisories_and_backgrounders/current_year/Pages/Dietary-kit-reduces-baby-blues,-a-precursor-to-postpartum-depression.aspx|CAMH: Dietary kit reduces baby blues, a precursor to postpartum depression]] | ||
| - | * [[http://www.jwatch.org/na44974/2017/09/07/effectiveness-postpartum-depression-screening-during-well]] | ||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||