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Postpartum Major Depression

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Postpartum Major Depression, Postpartum Depression, Postpartum Blues, Postnatal Depression, Peripartum Depression, Puerperal Depression, Antidepressants in Lactation, Antidepressants in Breast Feeding

  • See Also
  1. Antepartum Depression
  2. Major Depression
  • Epidemiology
  1. Postpartum Blues: 50-80% of post-partum women
  2. Postpartum Depression: 7-15% of post-partum women (within first 3 months of delivery)
  3. Postpartum Major Depression: 5-7% of post-partum women (within first 3 months of delivery)
  4. Postpartum Psychosis: 1-2 per thousand postpartum women
  • Risk Factors
  1. History of Major Depression is greatest risk factor (OR 29)
    1. Postpartum Depression with a prior pregnancy (recurrence in 25-50% of women)
    2. Antepartum Depression
    3. Prior history of Major Depression
  2. Prior history of other psychiatric disorder
  3. History of physical or sexual abuse
  4. Unplanned or Unwanted Pregnancy
  5. Pregnancy complications (pregnancy loss, preterm delivery)
  6. Emotional stress or maternal anxiety
  7. Lack of Social Support
  8. Single parent
  9. Lower socioeconomic status
  10. Gesational Diabetes (or pre-Gestational Diabetes)
  11. Fear of child birth
  12. Tobacco use
  13. Age over 40 years old or adolescent mothers
  14. Milgrom (2008) J Affect Disord 108(1-2):147-57 [PubMed]
  • Symptoms
  1. Depression lasts >2 weeks (contrast with Postpartum Blues)
  2. Comorbid anxiety and Agitation
  3. Most common symptoms
    1. Sadness is less commonly reported than in non-Postpartum Major Depression
    2. Guilt
    3. Worthlessness
    4. Anhedonia
    5. Decreased energy
    6. Difficulty sleeping when the baby is sleeping
  4. High risk symptoms (emergent mental health evaluation indications)
    1. Homicidal Thoughts
      1. Intrusive thoughts of hurting the newborn (may present as avoidance of the infant)
    2. Psychosis
      1. Hallucinations
      2. Delusions
      3. Rambling or pressured speech
    3. Suicidal thoughts
      1. Active Suicidal Ideation with a plan requires emergent psychiatric evaluation
      2. Passive Suicidal Ideation (e.g. no plan, but a wish go to sleep and not wake up) is more common
        1. Risk for progression to active Suicidal Ideation
  • Diagnosis
  1. See Major Depression Diagnosis
  2. Major Depression diagnosed during pregnancy or within 4 weeks postpartum
    1. Some experts recommend extending cut-off to one year after delivery
  • Differential Diagnosis
  1. Baby Blues
    1. Lasts <10 days (contrast with more than 2 weeks for depression)
    2. Onset within a few days of delivery
    3. Mild to no dysfunction (compared with moderate to severe dysfunction in depression)
  2. Bipolar Disorder
  3. Postpartum autoimmune Thyroiditis
  1. See Depression Screening Tools
  2. AAP recommends screening at perinatal visits and Well Child Visits (2, 4 and 6 months)
  3. USPTF recommends screening starting in second trimester for those with Peripartum Depression risk factors
  4. Edinburgh Postnatal Depression Scale
    1. http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
    2. 10 item, free tool, completed in <5 minutes, with good efficacy (>75% sensitive, >76% specific)
    3. Preferred first-line screening for Postpartum Depression over PHQ-9
  5. Patient Health Questionaire 9 (PHQ-9)
    1. Free tool, completed in <5 minutes, with good efficacy (>75% sensitive, 90% specific)
    2. Test Sensitivity
  6. Postpartum Depression Screening Scale (PDSS)
    1. Commercial product with 35 items, available for a fee
    2. Good efficacy (>91% sensitive, >72% specific)
  • Labs
  1. Thyroid Stimulating Hormone (TSH)
  • Management
  • Non-medication
  1. Psychotherapy (esp. Cognitive Behavioral Therapy)
  2. Adjust social situation
    1. Longer maternity leave
    2. Return part-time
  • Management
  • Medications
  1. Approach
    1. Typically taper off Antidepressants after 6-12 months of depression remission (esp. if first depression episode)
  2. Women not Breast Feeding
    1. Selective Serotonin Reuptake Inhibitors (SSRI)
  3. Women who are Breast Feeding
    1. Safest agents (undetectable in Breast Milk)
      1. Sertraline (Zoloft) - preferred agent
      2. Paroxetine (Paxil)
        1. However, Teratogenic if patient becomes pregnant again (therefore generally avoided)
    2. Agents with acceptably low levels in Breast Milk
      1. Escitalopram (Lexapro) - preferred agent
      2. Citalopram (Celexa)
      3. Venlafaxine (Effexor)
    3. Agents that are safe, but excessive sedation or other side effects
      1. Nortriptyline
      2. Mirtazapine (Remeron)
      3. Fluvoxamine (Luvox)
    4. Agents to avoid due to infant risks
      1. Fluoxetine (Prozac)
        1. Low levels in milk, but still more adverse effects in infants
        2. Teratogenic if patient becomes pregnant again (therefore generally avoided)
      2. Bupropion
        1. Risk of Seizures in newborns
  4. Refractory Postpartum Depression
    1. Intravenous Brexanolone
      1. Mimics Allopregnanolone (GABA Receptor agent) which normally decreases in peripartum period
      2. Intravenous infusion over 60 hours with onset of action by 24-48 hours
      3. Used in addition to standard SSRI agebts
      4. Risk of sedation and loss of consciousness (REMS program)
        1. Monitor for eccessive sedation and apnea (e.g. Pulse Oximetry)
      5. Astronomically expensive ($34,000)
      6. Unknown safety in Lactation
      7. (2019) Presc Lett 26(5)
  5. Avoid ineffective agents or those with insufficient evidence to support
    1. Avoid low dose Estrogen Replacement (also increases VTE Risk)
  • Complications
  1. Infant
    1. Failure to Thrive
    2. Attachment disorder
    3. Developmental Delay (at one year old)
  2. Mother
    1. Typical Major Depression symptoms (low energy, Insomnia, decreased concentration)
    2. Maternal Suicide
      1. Postpartum Suicide accounts for 20% of postpartum deaths
      2. Second only to Pulmonary Embolism as most common cause of postpartum death
  • Resources
  1. Patient Education materials form Minnesota Department of Health
    1. http://www.health.state.mn.us/divs/fh/mch/fhv/strategies/ppd/index.html
  2. Mothers and Babies Program (CBT Approach to counseling)
    1. http://www.mothersandbabiesprogram.org/
  3. Reach Out, Stand Strong, Essentials (ROSE) for New Mothers (interpersonal therapy approach to counseling)
    1. Taught as a part of some prenatal classes
    2. {https://www.publichealth.msu.edu/flint-research/the-rose-sustainment-study]
  • Prevention
  1. See Evaluation above for screening tools
    1. Perform at perinatal visits and Well Child Visits (esp. with risk factors present)
  2. Consider home health visits, peer support for high risk mothers
    1. First-time mothers
    2. Teen Mothers
    3. Traumatic delivery
  3. Counseling is effective and recommended by USPTF in the prevention of perinatal depression for those at risk
    1. See Risk Factors above
    2. Consider starting to screen for risk factors and Peripartum Depression in the second trimester of pregnancy
    3. See Evaluation Tools above for the diagnosis of perinatal depression
    4. Refer for Cognitive Behavioral Therapy (or interpersonal therapy) for those at risk
      1. Also see Resources above (e.g. Mothers and babies, ROSE Program)
  • References
  1. (2017) Presc Lett 24(4): 20
  2. (2019) Am Fam Physician 100(6): 364A-C [PubMed]
  3. Ahokas (2000) J Clin Psychiatry 61:166-9 [PubMed]
  4. Hirst (2010) Am Fam Physician 82(8): 926-33 [PubMed]
  5. Langan (2016) Am Fam Physician 93(10):852-8 [PubMed]
  6. Wisner (2002) N Engl J Med 347(3): 194-99 [PubMed]