The birth of a baby is usually an eagerly awaited and joyful event and a milestone in the life of a family. Many women are surprised, then, when this joyful event is followed by sadness, mood swings, and anhedonia. This response should not, however, be a surprise to medical providers. Postpartum depression (PPD) is the most common complication of childbearing, occurring in approximately 15% of women during the postpartum period, with some sources suggesting that the true incidence may be higher.1-4 The potential impacts on the mental and physical health of the mother and her infant may be profound and lifelong, as bonding, preventive care, and health maintenance are often suboptimal during the first few critical months of life. Beyond the clinical implications for both the mother and her infant, direct and indirect financial implications of this condition are substantial as well.5
Given the frequency and severity of PPD, all medical providers should recognize the signs of PPD and know the basics of therapy. In particular, PAs working in obstetrics and gynecology, pediatrics, and family and emergency medicine should be knowledgeable regarding this common complication. This article will review the pathophysiology, risk factors, signs and symptoms, diagnosis, treatment, and sequelae of postpartum depression.
The definition of perinatal depression differs from other forms of depression only in terms of timing. The Diagnostic and Statistics Manual, Fourth Edition, Text Revision (DSM-IV-TR) defines postpartum depression by adding a specifier to the discussion of major depressive disorder (MDD), citing an onset of depressive symptoms within 4 weeks of giving birth.6 Clinically, however, PPD is often diagnosed when symptoms occur within 12 months of a child's birth.2
Most women will experience mood swings, commonly called the baby blues, in the weeks following the birth of a child. This condition is usually mild and transitory, resolving in the first 10 days of an infant's life, and is not accompanied by suicidal ideation.2 The practicing PA should be diligent in differentiating between this common occurrence and a true major depressive episode. Additionally, patients and their partners should be educated regarding warning signs of a true depressive disorder and encouraged to contact their medical provider if significant concerns arise.
All clinicians, especially those practicing in primary care fields and emergency medicine, must be able to differentiate the more serious postpartum psychosis from these other conditions (Table 1). Postpartum psychosis has a rapid onset, generally occurring within the first 4 weeks after childbirth but in some cases as early as 2 days postpartum. Patients may develop paranoid, grandiose, or bizarre delusions; mood swings; confused thinking; and disorganized behavior, all of which vary from their normal state. In many cases, postpartum psychosis is a manifestation of bipolar disorder. The disorder is a psychiatric emergency in which the safety of the new mother and her child or children may be jeopardized; for example, a mother may hear voices telling her she should kill her infant. Immediate treatment, including hospitalization, must be considered for this population.7
PATHOPHYSIOLOGY OF PPD
Despite increasing awareness of PPD, little is known about its specific etiology. Suggested mechanisms include changes in estrogen, progesterone, serotonin, monoamine oxidase A (MAO-A) and gamma-aminobutyric acid (GABA) levels.3,5,8,9 Alternations in the hypothalamic-pituitary axis and thyroid dysfunction have also been considered, as well as decreased levels of the omega-3 polyunsaturated fatty acid (PUFA) docosahexaenoic acid (DHA).1,4,9,10 Furthermore, promising epigenetic studies suggest that genetic predisposition may play a significant role in a woman's response to environmental factors regarding PPD development.4,11
Elevated levels of estrogen and progesterone that are present in the third trimester of pregnancy are known to drop exponentially early in the postpartum period.9 Estrogen appears to affect serotonin levels and serotonin receptors both directly and secondarily through MAO-A levels,3,5 while progesterone appears to affect GABA-A receptors.3,8 Given estrogen's effect on MAO-A levels, there is further potential for a secondary effect on dopamine and norepinephrine levels.3 Because serotonin, MAO-A, and GABA have well-documented relationships with psychiatric diseases,3,8 hormonal shifts may contribute to an episode of PPD in predisposed individuals.
Although decreased activation of the hypothalamic-pituitary axis after childbirth has been hypothesized as a contributing factor in the development of PPD, an exact mechanism remains unclear.9,12 In addition, approximately 6% to 9% of women develop postpartum thyroiditis, which may present with symptoms of either hyperthyroidism or hypothyroidism. Because depressive symptoms are typical of hypothyroidism, connection between postpartum thyroiditis and PPD has been hypothesized.1,2 Regardless of the etiology, postpartum thyroiditis must be included in the differential diagnosis of a woman presenting with PPD.
Another factor that may contribute to postpartum depression is the decrease of maternal brain DHA and other omega-3 PUFAs during pregnancy. However, brain fattyacid content has not been studied extensively in humans.10
Women diagnosed with PPD often demonstrate one or more of the following risk factors: history of a depressive episode or MDD; gestational diabetes; multiple gestation; poor marital and social support; and stressful life events, including the stress associated with child care.2,9,13-15 The most significant factors appear to be a history of a depressive episode or MDD and occurrence of stressful life events. Low socioeconomic status has also been postulated to be a risk factor for PPD, but research has been inconclusive.16,17
- Postpartum depression is the most common complication of childbearing, occurring in as many as 15% of women during the postpartum period, with some sources suggesting the true incidence may be higher. Thus, all medical providers should know the signs of postpartum depression and the basics of therapy.
- Patients with postpartum psychosis may develop paranoid, grandiose, or bizarre delusions; mood swings; confused thinking; and disorganized behavior. This is a psychiatric emergency in which the safety of the new mother and her child or children may be jeopardized; for example, a mother may hear voices telling her she should kill her infant.
- Among the treatment options are pharmacotherapy, including antidepressants and hormone administration, and psychological modalities, including cognitive behavior and interpersonal therapy. Other approaches include exercise, bright light therapy, and acupuncture and massage, as well as prescription of omega-3 polyunsaturated fatty acids.
SCREENING AND DIAGNOSIS
Postpartum screening is recommended by numerous sources, including the American Academy of Pediatrics (AAP)18 and the Academy of Breastfeeding Medicine.19 Legislation has been passed at the national level and by several states to improve screening, treatment, and education for postpartum depression.20 The American College of Obstetrics and Gynecology recommends that both antenatal and postnatal screening for depression be “strongly considered,” although the organization stops short of recommending universal screening at this time.21
Multiple tools exist to screen for PPD. The most commonly used instrument is the Edinburgh Postnatal Depression Scale (EPDS), which is both sensitive and specific in detecting postpartum depression.2 This easily readable questionnaire assesses a patient's mood over the past week. The 10-question form, which asks respondents to choose from a closed set of possible responses, can be completed and scored in just a few moments. Each response is given a score of 0 to 3. A total score of greater than 12 or any positive response to the item “the thought of harming myself has occurred to me” should prompt a more complete assessment for depression.2 The questionnaire can be accessed online and is most commonly administered at the 6-week postpartum visit of the mother or at the 2-month well-child checkup. Translations are available in more than 35 languages.22
Other validated screening tools include the Center for Epidemiologic Studies of Depression instrument (CES-D), the Patient Health Questionnaire (PHQ-9), and the Postpartum Depression Screening Scale (PDSS).23 These instruments are useful for screening, but they should not be used alone to make the diagnosis of PPD. Rather, a positive screen should prompt the clinician to conduct a complete interview to determine if the patient meets criteria for a major depressive episode.
Major depressive disorder, as outlined in the DSM-IV-TR, is characterized by a possible symptom combination of depressed mood, anhedonia, change in weight or appetite, sleep disturbance, inappropriate guilt, psychomotor disturbance, fatigue, diminished concentration, or thought of death or suicide.6 Five of these symptoms must be present within a 2-week period, and one of the five must be either depressed mood or anhedonia to make a diagnosis of MDD.6 As previously noted, a designation of symptom onset within 4 weeks following birth allows for a diagnosis of PPD.6 Recent expert opinions suggest that onset within the first 3 months is a more clinically accurate criterion, and that symptom onset of PPD may occur at any point within the first 12 months after childbirth.2
One notable limitation in the definition of PPD is that the postpartum onset specifier in the DSM-IV-TR does not account for whether or not depressive symptoms were present during time periods prior to pregnancy. In addition, many of the symptoms (sleep deprivation, weight changes, fatigue) may be experienced as part of routine infant care or secondarily from sleep deprivation related to infant care and do not constitute a depressive episode on their own.2 Thus, a detailed history is crucial to carefully differentiate between PPD and a normal postpartum course.
Pharmacologic options, psychological therapy, and other therapeutic approaches are available for the treatment of PPD. Counseling, the use of medications, or both are often considered first-line therapy, with other options used as adjuvant therapy.
Psychological or psychosocial options Psychotherapy is an effective treatment for PPD, particularly in women with mild to moderate symptoms. This approach may be a particularly attractive option to women who are breastfeeding and wish to avoid pharmacotherapy because of the effects of certain medications, eg, antidepressants, on themselves and the infant. Psychotherapy may also be used effectively in combination with pharmacotherapy.2 Commonly used psychological modalities include cognitive behavior therapy, in which patients are encouraged to change thought patterns and improve coping behaviors, and interpersonal therapy, a time-limited, problem-focused modality. Nondirective counseling and enhancement of peer and partner support are strategies also supported by the literature.24
Pharmacologic options While women may be hesitant to use medicines, particularly while nursing, many current medications are effective in the treatment of PPD.24 The choice to use antidepressants may be based in part on the severity of the depression, availability and affordability of psychotherapy, and patient desires.24 Among the pharmacologic options, the selective serotonin reuptake inhibitors (SSRIs) are considered to be the first-line choice for postpartum depression. Fluoxetine, paroxetine, and sertraline have each been effective in clinical trials.25
Tricyclic antidepressants (TCAs), such as nortriptyline and imipramine, are well-studied and have proven effective in many cases. However, they remain second-line medications because of safety concerns, such as the risk of overdose.25
A third class of treatment is hormonal therapy. Because the postpartum drop in estrogen levels may contribute to the onset of depression, transdermal estradiol has been tried, with some limited success. However, more data are needed before a clinical recommendation can be made.25
Regardless of which medication is chosen, prescribe the starting dose for 4 days. If that dose is well-tolerated, increase the amount of medication to the lowest dosage in the usual treatment range. Concomitant lifestyle modifications should be encouraged. After the depression has resolved, women should be treated for an additional 6 to 9 months before tapering the medication in order to avoid relapse.2
Antidepressants and breastfeeding The use of antidepressants is a difficult choice for many patients and practitioners when a woman is breastfeeding. The benefits of breastfeeding for both the mother and infant are well-understood, and women are strongly encouraged to breastfeed exclusively for the first 6 months of their child's life by both the AAP and the World Health Organization.26,27 There is little evidence suggesting that breastfeeding while using certain antidepressants is unsafe, but long-term data are limited. Thus, the use of antidepressants in breastfeeding women is a decision to be carefully considered and made by the patient in conjunction with her medical provider. Sertraline and paroxetine may be considered in women who are naive to antidepressant use, as the excretion of these agents in breast milk is very low.28 However, paroxetine has been linked to an increased risk of cardiac defects in the developing fetus and should thus be used with caution in a woman who may become pregnant again while undergoing therapy.28
Continuing use of a medication to which the patient has already responded well is reasonable, unless there is evidence that the medication is unsafe in lactation.2 Safety of medications in lactation may be checked online at LactMed, a peer-reviewed and referenced database of drugs to which breastfeeding mothers may be exposed. The database provides such information as the level of each medication secreted in breast milk, the possible effects on infants and on a mother's ability to produce milk, and other drugs that may be used instead.29
Additional therapeutic options Other modalities exist that may be beneficial to women with PPD. These include exercise, bright light therapy, and acupuncture and massage.24 While efficacy data are limited, all these options are relatively safe and may have other health benefits. Electroconvulsive therapy may also be considered for depression that is refractory to other treatments.24
Finally, omega-3 PUFAs, such as eicosapentaenoic acid (EPA) and DHA, have been considered as possible alternative therapy, as these agents are associated with fewer adverse effects for both the mother and child. However, study results have been mixed in terms of the efficacy of PUFAs in reducing symptoms of postpartum depression.30,31 Further research is needed to determine whether PUFAs can be an effective alternative to antidepressant use in the postpartum period.
SEQUELAE OF PPD
The most concerning factor of PPD is the significant impact of this disorder on both the mother and her child. Mothers with PPD may feel a sense of detachment from their infants. Combined with the widespread cultural assumption that motherhood should be a time of elation in a woman's life, the symptoms of PPD may caus e feelings of guilt in a new mother who is not enjoying this period.2 Such feelings often serve to worsen PPD symptoms. In addition, PPD may decrease the quality of the relationship between the mother and her partner.32
Symbol SEE THE ONLINE VERSION OF THIS ARTICLE TO LINK TO
The Edinburgh Postnatal Depression Scale http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
Mothers with PPD are more likely to utilize health care resources for somatic complaints than mothers without PPD.33 Whether or not maternal suicide occurs more often in women with MDD during the postpartum period than in women with MDD who are not postpartum remains controversial.2,9,12,32 Regardless, suicide remains a significant concern, and aggressive screening for suicidal ideations should be performed.
PPD can have long-lasting effects on the child. Mothers with PPD may spend less time engaged in bonding activities, developmental activities, or even play, and tactile stimulation and soothing of their infants may be decreased.9,30,34 Such behaviors can negatively impact the development of the child's communication and language skills.12 Additionally, maternal PPD can increase the risk of low self-esteem, depression or anxiety disorders, or conduct disorder during childhood to adolescence.12 In their role as caregiver, mothers with PPD have been shown to access preventive care, including well-baby visits and routine vaccinations, at a decreased rate while utilizing emergency services for their infants at a higher rate than mothers without PPD.33,34 Poor health, along with sleep and behavior problems of the infant, are often reported by mothers with PPD.12,33 Women with PPD are less likely to breastfeed and to ensure routine safety measures for their infants.9,12,34 Postpartum depressive mothers have also shown more aggressive behavior toward the infant or fear of being alone with the baby.2,34 In cases of severe PPD, aggressive behavior directed toward the infant may result in abuse or infanticide,12 as well as serving as an additional cause for the previously discussed psychiatric disorders observed in children of depressed mothers.
Postpartum depression can make the first months of an infant's life challenging for both the mother and her newborn child. With careful screening, diagnosis, and treatment, however, PAs can help new parents through this transition to ensure the healthiest family possible.
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EARN CATEGORY I CME CREDIT by reading this article and the article beginning on page 26 and successfully completing the posttest on page 55. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of February 2013.