Postpartum Depression
last authored: Feb 2011, Laura Orlando
last reviewed: March 2011, Myrlinda Barral
Introduction
About 85% of women will experience some degree of mood disturbances during the postpartum period. Most of these women have mild symptoms, a condition commonly known as the “postpartum blues”, while the minority of women will suffer from major depression or psychosis. Postpartum blues refers to a temporary condition of two weeks or less, characterized by mild, and often rapid, mood swings from elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, and crying spells. Women with postpartum blues are at increased risk of developing postpartum depression (PPD).
A diagnosis of major and minor depression requires that depressed mood or loss of interests/pleasure and other characteristic symptoms be present most of the day, nearly every day, for at least two weeks. It often goes unrecognized because many of the usual discomforts of the puerperium (eg, fatigue, difficulty sleeping, low libido) are similar to symptoms of depression. PPD occurs in 12-13% of all new births across a range of cultures (O'Hara et al, 1996). It does not appear that the prevalence of PPD is affected by cultural group or socioeconomic status.
Trotula of Salerno: "if the womb is too moist, the brain is filled with water, and the moisture running over to the eyes..."
The Case of "Stephanie" (Zauderer, 2008)
"Stephanie was a 29-year-old primiparous mother of a baby girl named Emma. She came to her family physician for care when Emma was 6 weeks old and presented with moderate to severe depressive symptoms, which had been ongoing for 2 weeks. Her symptoms included sleep disturbance, loss of appetite, and panic attacks. In addition to these symptoms, Stephanie complained about not having “normal” feelings toward Emma. She felt as though the baby was not hers and that she was a total stranger. Stephanie stated that she did not retain any of the prior good feelings she had while she was pregnant and felt that although she had bonded with the newborn in utero, those feelings were now gone."
- What further questions would you like to ask?
- What investigations would you like to order?
- What is your differential diagnosis?
Causes and Risk Factors
Causes and risk factors for postpartum depression include:
- A personal history of depression (prior to pregnancy or postpartum) is the major risk factor for PPD; one-half of women with PPD have onset of symptoms before or during their pregnancies
- Marital conflict
- Stressful life events in the previous 12 months
- Lack of perceived social support from family and friends for the pregnancy
- Lack of emotional and financial support from the partner
- Living without a partner
- Unplanned pregnancy
- Having contemplated terminating the current pregnancy
- Previous miscarriage
- Family psychiatric history (Consistent 10% risk for first-degree relatives of sufferers from major depression)
- A poor relationship with one’s own mother
- Not breastfeeding
- Unemployment in the mother or in the head of household
- A lifetime history of depression in the husband or partner
- Child-care related stressors
- Sick leave during pregnancy related to hyperemesis, uterine irritability, or psychiatric disorder
- High number of visits to prenatal clinic
- A congenitally malformed infant
- Personality factors (high neuroticism and high introversion)
- Pregestational or gestational diabetes
- Personal history of bipolar disorder
Pathophysiology
The underlying causes of PPD are unclear. The condition may affect some women and not others due to the interaction of genetic susceptibility with major life events and hormonal changes. Although estrogen, progesterone, thyroid hormone, testosterone, cholesterol, corticotropin-releasing hormone, and cortisol have all been studied, no hormonal factor has emerged as a causative agent. There is a 10x drop in estrogen with the delivery of the placenta alone. Estrogen can act as an agonist in the serotonergic system, and estrogen modulation in pre-menstrual dysphoric disorder and menopause can impact mood symptoms.
Signs and Symptoms
- history
- physical exam
History
“Postpartum depression” is a term commonly used to describe depression that begins within the first month after delivery, using the same criteria as for nonpregnancy related depression. It is not considered a separate diagnosis in the DSM-IV. Diagnosis of DSM-IV major depression requires five or more of the following, with at least one of the first two:
- depressed mood
- loss of pleasure and interest in activities
- significant weight loss
- insomnia or hypersomnia
- agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or guilt
- loss of concentration
- recurrent thoughts of death or suicide
Clinically, PPD may manifest as changes in somatic functions such as sleep, energy level, appetite, weight, gastrointestinal functioning, and libido. Other symptoms include:
- Clinically significant anxiety and accompanying panic attacj
- Anger and irritability
- Feelings of guilt
- Feeling overwhelmed or being unable to care for the infant
- Feelings of failure as a mother
- Failure to bond with the baby
The Edinburgh Postnatal Depression Scale (EPDS) is a 10 item self-report questionnaire designed specifically for the detection of depression in the postpartum period. A score of 9 or 10 indicates follow-up with a brief diagnostic interview to confirm depression.
NOTE: always ask about symptoms of mania or hypomania, so as not to miss a diagnosis of bipolar disorder.
Physical Exam
A routine physical exam should be performed to rule out physical causes of depression. It is important to pay attention to evidence of self-neglect (such as weight loss), signs of self-harm (such as scars on wrists), drug injection sites, injuries that may be the result of alcohol or drug misuse, and restlessness, agitation, and psychomotor retardation.
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
It is important to obtain routine laboratory investigations to exclude other diagnoses. Minimum routine investigations include a complete blood count, blood chemisty, urinalysis, liver function tests, and thyroid function tests. If the routine laboratory testing comes back negative for all organic disorders, consider formal psychological testing to diagnoses depression and to assess its severity.
Diagnostic Imaging
Differential Diagnosis
The differential diagnosis for postpartum depression includes:
- Postpartum blues
- Postpartum psychosis
- Post-traumatic stress disorder (can result as a consequence of painful labour)
- Dysthymia (a low-grade mood disturbance not better accounted for by major depression)
- Hypothyroidism
- Mononucleosis
- Anemia
- Bipolar disorder
- Schizophrenia
- Medication side-effects (Drugs such as benzodiazepines and antihypertensives may cause symptoms that mimic depression)
- Substance withdrawal
Treatments
As with all conditions, prevention is ideal. This includes close follow-up if increased risk for depression is suspected. Encouragement of healthy choices and attachment with the infant, such as through breastfeeding, may be beneficial.
If depression is diagnosed, before initiating treatment, it must first be determined if there the patient is a risk to herself or others, particularly the baby.
Once any acute risk has been ruled out, a biopsychosocial approach to treatment is often utilized to maximize clinical response. To address the biological factors, treatments such as sleep hygiene, pharmacotherapy, light therapy and/or electroconvulsive therapy may be initiated. Psychological and social factors can be addressed with individual or group psychotherapy, as well as the appropriate social services.
There are few studies that have examined the safety of antidepressants. Sertraline, paroxetine, and fluoxetine are SSRI's that are used, while nortriptyline is a TCA that may be trialed. None of these are detectable in breastmilk.
Few studies have systematically examined the efficacy of nonpharmacological and pharmacological therapies for the treatment of PDD. Appleby and colleagues (1997) showed that short-term CBT was just as effective as treatment with fluoxetine in postpartum depression.
Consequences and Course
Thoughts of harming oneself or the infant are the most important complications of PDD, however this is more likely to occur with postpartum psychosis than with postpartum depression. In addition, PPD can interfere with maternal-infant bonding and can adversely affect the infant’s cognitive, emotional, behavioral, and social development. For instance, increased rates of cognitive and attention deficits have been found in children exposed to maternal psychiatric illnesses. In addition, marital stress is both a risk factor and consequence of PDD.
In women who suffer from PDD, there is an increased risk for further episodes of major depression. About 15-85% of women will experience at least one additional episode after medication cessation and with future deliveries. Compliance greatly improves prognosis.
Resources and References
Appleby L, Warner R, Whitton A, et al. 1997. A controlled study of fluoxetine and cognitive-behavioral counselling in the treatment of postnatal depression. BMJ 314(7085):932-936.
First Consult: Postpartum Depression
Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed. Chapter 31: Psychiatric Illness during Pregnancy and the Postpartum Period.
UptoDate: Postpartum Blues and Depression.
Zauderer, CR. 2008. “A case study of postpartum depression & altered maternal-newborn attachment.” MCN Am J Matern Child Nurs 33(3): 173-178.
Topic Development
authors: Feb 2011, Laura Orlando
reviewers: March 2011, Dr Myrlinda Barral
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